IPPtll  ilHt'm  llliHllHllif 


^T^gg-^arriirT^yarTTtfrr^^^ 


Digitized  by  the  Internet  Arciiive 

in  2007  witin  funding  from 

IVIicrosoft  Corporation 


littp://www.arcliive.org/details/bronclioscopyesopOOjackiala 


^BRONCHOSCOPY 

AND 

ESOPHAGOSCOPY 

A  MANUAL  OF  PERORAL  ENDOSCOPY 
AND  LARYNGEAL  SURGERY 


By 

V 
CHEVALIER  JACKSON,  M.D.,  F.A.C.S. 

Professor  of  Laryngology,  Jefferson  Medical  College,  Philadelphia;  Professor 
of  Bronchoscopy  and  Esophagoscopy,  Graduate  School  of  Medicine,  Uni- 
versity of  Pennsylvania;  Member  of  the  American  Laryngological  Association; 
Member  of  the  Laryngological,  Rhinological,  and  Otological  Society;  Member 
of  the  American  Academy  of  Ophthalmology  and  Oto-Laryngology;  Member 
of  the  American  Bronchoscopic  Society;  Member  of  the  American  Philo 
sophical  Society;  etc..  etc. 


WITH  114  ILLUSTRATIONS 
AND  FOUR  COLOR  PLATES 


PHILADELPHIA  AND  LOXDOX 

W.  B.  SAUNDERS  COMPANY 

1922 


VJF  \M| 


Copyright,  1922,  by  W.  B.  Saunders  Company 


MADE    IN     U.     S.    A. 


To 

My  Mother 

To  Whose  Interest  in  Medical  Science 

The  Author  Owes  His  Incentive, 

And  to 

My  Father 

Whose  Constant  Advice  to 

"Educate  the  Eye  and  the  Fingers" 

Spurred  the  Author  to  Continual  Effort, 

This  Book  is  Affectionately  Dedicated. 


PREFACE 


This  book  is  based  on  an  abstract  of  the  author's  larger  work, 
Peroral  Endoscopy  and  Laryngeal  Surgery.  The  abstract  was 
prepared  under  the  author's  direction  by  a  reader,  in  order  to  get  a 
reader's  point  of  view  on  the  presentation  of  the  subject  in  the 
earlier  book.  With  this  abstract  as  a  starting  point,  the  author 
has  endeavored,  so  far  as  lay  within  his  limited  abilities,  to  accom- 
plish the  difficult  task  of  presenting  by  written  word  the  various 
purely  manual  endoscopic  procedures.  The  large  number  of 
corrections  and  revisions  found  necessary  has  confirmed  the 
wisdom  of  the  plan  of  getting  the  reader's  point  of  view;  and  these 
revisions,  together  with  numerous  additions,  have  brought  the 
treatment  of  the  subject  up  to  date  so  far  as  is  possible  within  the 
limits  of  a  working  manual. 

Acknowledgment  is  due  the  personnel  of  the  W.  B. 
Saunders  Company  for  kindly  help. 

Chevalier  Jackson. 

October,  1922. 


CONTENTS 


Page 
CHAPTER  I 


Instrumentarium. 


17 


CHAPTER  II 


Anatomy  of  Larynx,  Trachea,  Bronchi  and  Esophagus,  Endoscopically 
Considered 52 

CHAPTER  III 
Preparation  of  the  Patient  for  Peroral  Endoscopy 63 

CHAPTER  IV 

Anesthesia  for  Peroral  Endoscopy 65 

CHAPTER  V 
Bronchoscopic  Oxygen  Insufflation 71 

CHAPTER  VI 

Position  of  the  Patient  for  Peroral  Endoscopy 73 

CHAPTER  VII 

Direct  Laryngoscopy 82 

CHAPTER  VIII 
Direct  Laryngoscopy  (Conlimicd) 91 

CHAPTER  IX 

Introduction  of  the  Bronchoscope 97 

CHAPTER  X 

Introduction  of  the  Esophagoscope 106 

CHAPTER  XI 

Acquiring  Skill ^^7 

CHAPTER  XII 

Foreign  Bodies  in  the  Air  and  Food  Passages 126 

13 


14  CONTENTS 

Page 
CHAPTER  XIII 

Foreign  Bodies  in  the  Larynx  and  Tracheobronchial  Tree 149 

CHAPTER  XIV 

Removal  of  Foreign  Bodies  from  the  Larynx 156 

CHAPTER  XV 

Mechanical  Problems  OF  Bronchoscopic  Foreign  Body  Extraction.    .    .    .   158 

CHAPTER  XVI 
Foreign  Bodies  in  the  Bronchi  for  Prolonged  Periods 177 

CHAPTER  XVII 

Unsuccessful  Bronchoscopy  for  Foreign  Bodies 181 

CHAPTER  XVIII 

Foreign  Bodies  in  the  Esophagus 183 

CHAPTER  XIX 

Esophagoscopy  for  Foreign  Body 187 

CHAPTER  XX 
Pleuroscopy 199 

CHAPTER  XXI 

Benign  Growths  in  the  Larynx 201 

CHAPTER  XXII 

Benign  Growths  in  the  Larynx  {Continued) 203 

CHAPTER  XXIII 

Benign  Growths  Primary  in  the  Tracheobronchial  Tree 207 

CHAPTER  XXIV 

Benign  Neoplasms  of  the  Esophagus 209 

CHAPTER  XXV 

Endoscopy  in  Malignant  Disease  of  the  Larynx 210 

CHAPTER  XXVI 
Bronchoscopy  in  Malignant  Growths  of  the  Trachea 214 

CHAPTER  XXVII 

Malignant  Disease  of  the  Esophagus 216 


CONTENTS  15 

Page 
CHAPTER  XXVIII 

Direct  Laryngoscopy  in  Diseases  of  the  Larynx 221 

CHAPTER  XXIX 

Bronchoscopy  in  Diseases  of  the  Trachea  and  Bronchi 224 

CHAPTER  XXX 

Diseases  of  the  Esophagus 235 

CHAPTER  XXXI 

Diseases  of  the  Esophagus  (Continued) 245 

CHAPTER  XXXII 

Diseases  of  the  Esophagus  (Continued) 25 1 

CHAPTER  XXXIII 

Diseases  of  the  Esophagus  (Conlimied) 260 

CHAPTER  XXXIV 

Diseases  of  the  Esophagus  (Continued) 268 

CHAPTER  XXXV 
Gastroscopy 273 

CHAPTER  XXXVI 

Acute  Stenosis  of  the  Larynx 277 

CHAPTER  XXXVII 
Tracheotomy 279 

CHAPTER  XXXVIII 

Chronic  Stenosis  of  the  Larynx  and  Trachea 300 

CHAPTER  XXXIX 

Decannulation  after  Cure  of  Laryngeal  Stenosis 309 

Bibliography 311 

Index 315 


BRONCHOSCOPY 

AND 

ESOPHAGOSCOPY 

CHAPTER  I 
INSTRUMENTARIUM 

Direct  laryngoscopy,  bronchoscopy,  esophagoscopy  and  gas- 
troscopy  are  procedures  in  which  the  lower  air  and  food  passages 
are  inspected  and  treated  by  the  aid  of  electrically  lighted  tubes 
which  serve  as  specula  to  manipulate  obstructing  tissues  out  of  the 
way  and  to  bring  others  into  the  line  of  direct  vision.  Illumina- 
tion is  supplied  by  a  small  tungsten-filamented,  electric,  "cold" 
lamp  situated  at  the  distal  extremity  of  the  instrument  in  a  special 
groove  which  protects  it  from  any  possible  injury  during  the  intro- 
duction of  instruments  through  the  tube.  The  bronchi  and  the 
esophagus  will  not  allow  dilatation  beyond  their  normal  caUber; 
therefore,  it  is  necessary  to  have  tubes  of  the  sizes  to  fit  these 
passages  at  various  developmental  ages.  Rupture  or  even  over- 
distention  of  a  bronchus  or  of  the  thoracic  esophagus  is  almost 
invariably  fatal.  The  armamentarium  of  the  endoscopist  must 
be  complete,  for  it  is  rarely  possible  to  substitute,  or  to  improvise 
makeshifts,  while  the  bronchoscope  is  in  situ.  Furthermore, 
the  instruments  must  be  of  the  proper  model  and  well  made;  other- 
wise difficulties  and  dangers  will  attend  attempts  to  use  them. 

Laryngoscopes. — The  regular  type  of  laryngoscope  shown  in 
Fig.  I  (A,  B,  C)  is  made  in  adult's,  child's,  and  infant's  sizes. 
The  instruments  have  a  removable  slide  on  the  top  of  the  tubular 

2  17 


BRONCHOSCOPY  AND  ESOPHAGOSCOPY 


m 


1 


^^ 


Fig.  I. — Author's  laryngoscopes.  These  are  the  standard  sizes  and  fulfill  all 
requirements.  Many  other  forms  have  been  devised  by  the  author,  but  have  been 
omitted  from  the  list  as  unnecessary.  The  infant  diagnostic  laryngoscope  (C)  is  not 
for  introducing  bronchoscopes,  and  is  not  absolutely  necessary,  as  the  larynx  of  any 
infant  can  be  inspected  with  the  child's  size  laryngoscope  (B). 

A  Adult's  size;  B,  child's  size;  C,  infant's  diagnostic  size;  D,  anterior  commissure 
laryngoscope;  E,  with  drainage  canal;  F,  intubating  laryngoscope,  large  lumen.  All 
the  laryngoscopes  are  preferred  without  drainage  canals. 


IXSTRUMEXTARIUM  1 9 

portion  of  the  speculum  to  allow  the  removal  of  the  laryngoscope 
after  the  insertion  of  the  bronchoscope  through  it.  The  infant 
size  is  made  in  two  forms,  one  with,  the  other  without  a  removable 
slide;  with  either  form  the  larynx  of  an  infant  can  be  exposed  in 
but  a  few  seconds  and  a  definite  diagnosis  made,  without  anesthe- 
sia, general  or  local;  a  thing  possible  by  no  other  method.  For 
operative  work  on  the  larynx  of  adults,  such  as  the  removal  of 
benign  growths,  particularly  when  these  are  situated  in  the  ante- 
rior portion  of  the  larynx,  a  special  tubular  laryngoscope  having 
a  heart-shaped  lumen  and  a  beveled  tip  is  used.  With  this 
instrument  the  anterior  commissure  is  readily  exposed,  and  be- 
cause of  this  it  is  named  the  anterior  commissure  laryngoscope  (Fig. 
I,  D).  The  tip  of  the  anterior  commissure  laryngoscope  can  be 
used  to  expose  either  ventricle  of  the  larynx  by  lifting  the  ven- 
tricular band,  or  it  may  be  passed  through  the  adult  glottis  for  work 
in  the  subglottic  region.  This  instrument  may  also  be  used  as  an 
esophageal  speculum  and  as  a  pleuroscope.  A  side-slide  laryngo- 
scope, used  with  or  without  the  slide,  is  occasionally  useful. 

Bronchoscopes. — The  regular  bronchoscope  is  a  hollow  brass 
tube  slanted  at  its  distal  end,  and  having  a  handle  at  its  proximal  or 
ocular  extremity.  An  auxiliary  canal  on  its  under  surface  contains 
the  light  carrier,  the  electric  bulb  of  which  is  situated  in  a  recess 
in  the  beveled  distal  end  of  the  tube.  Numerous  perforations  in 
the  distal  part  of  the  tube  allow  air  to  enter  from  other  bronchi 
when  the  tube-mouth  is  inserted  into  one  whose  aerating  function 
may  be  impaired.  The  accessory  tube  on  the  upper  surface  of  the 
bronchoscope  ends  within  the  lumen  of  the  bronchoscope,  and  is 
used  for  the  insufflation  of  oxygen  or  anesthetics,  (Fig.  2,  A,  B,  C, 
D). 

For  certain  work  such  as  drainage  of  pulmonary  abscesses,  the 
lavage  treatment  of  bronchiectasis  and  for  foreign-body  or  other 
cases  with  abundant  secretions,  a  drainage-bronchoscope  is  useful 


20 


BRONCHOSCOPY  AND  ESOPHAGOSCOPY 


.^.= 


Fig.  2. — The  author's  bronchoscopes  of  the  sizes  regularly  used.  Various  other 
lengths  and  diameters  are  on  hand  for  occasional  use  for  special  purposes.  With  the 
exception  of  a  6  mm.  X  35  cm.  size  for  older  children,  these  special  bronchoscopes 
are  very  rarely  used  and  none  of  them  can  be  regarded  as  necessary.  For  special 
purposes,  however,  special  shapes  of  tube-mouth  are  useful,  as,  for  instance,  the 
oval  end  to  facilitate  the  getting  of  both  points  of  a  staple  into  the  tube-mouth 
The  illustrated  instruments  are  as  follows: 

A,  Infant's  size,  4  mm.  X  30  cm.;  B,  child's  size,  5  mm.  X  30  cm.;  C,  adolescent's 
size,  7  mm.  X  40  cm.;  D,  adult's  size,  9  mm.  X  40  cm.;  E,  aspirating  bronchoscope 
made  in  all  the  foregoing  sizes,  and  in  a  special  size,  5  mm.  X  45  cm. 


INSTRUMEXTARIUM  21 

(Fig.  2,  E).  The  drainage  canal  may  be  on  top,  or  on  the  under 
surface  next  to  the  light-carrier  canal.  For  ordinary  work,  how- 
ever, secretion  in  the  bronchus  is  best  removed  by  sponge-pump- 
ing (q.v.)  which  at  the  same  time  cleans  the  lamp.  The  drainage 
bronchoscope  may  be  used  in  any  case  in  which  the  very  slightly- 
greater  area  of  cross  section  is  no  disadvantage;  but  in  children  the 
added  bulk  is  usually  objectionable,  and  in  cases  of  recent  foreign- 
body,  secretions  are  not  troublesome. 

As  before  mentioned,  the  lower  air  passages  will  not  tolerate 
dilatation;  therefore,  it  is  necessary  never  to  use  tubes  larger  than 
the  size  of  the  passages  to  be  examined.  Four  sizes  are  sufficient 
for  any  possible  case,  from  a  newborn  infant  to  the  largest  adult. 
For  infants  under  one  year,  the  proper  tube  is  the  4  mm.  by  30  cm.; 
the  child's  size,  5  mm.  by  30  cm.,  is  used  for  children  aged  from 
one  to  five  years.  For  children  six  years  or  over,,  the  7  mm.  by  40 
cm.  bronchoscope  (the  adolescent  size)  can  be  used  unless  the 
smaller  bronchi  are  to  be  explored.  The  adult  bronchoscope 
measures  9  mm.  by  40  cm. 

The  author  occasionally  uses  special  sizes,  5  mm.  X  45  cm., 
6  mm.  X  35  cm.,  8  mm.  X  40  cm. 

Esophagoscopes. — The  esophagoscope,  like  the  bronchoscope, 
is  a  hollow  brass  tube  with  beveled  distal  end  containing  a  small 
electric  Hght.  It  differs  from  the  bronchoscope  in  that  it  has  no 
perforations,  and  has  a  drainage  canal  on  its  upper  surface,  or 
next  to  the  light-carrier  canal  which  opens  within  the  distal  end 
of  the  tube.  The  exact  size,  position,  and  shape,  of  drainage 
outlets  is  important  on  bronchoscopes,  and  to  an  even  greater 
degree  on  esophagoscopes.  If  the  proximal  edge  of  the  drainage 
outlet  is  too  near  the  distal  end  of  the  endoscopic  tube,  the  mucosa 
will  be  drawn  into  the  outlet,  not  only  obstructing  it,  but,  most 
important,  traumatizing  the  mucosa.  If,  for  instance,  the  esopha- 
goscope were  to  be  pushed  upon  with  a  fold  thus  anchored  in  the 


2  2  '  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

distal  end,  the  esophageal  wall  could  easily  be  torn.     To  admit 
the  largest  sizes  of  esophagoscopic  bougies  (Fig.  40),  special  eso- 


FiG.  3. — The  author's  esophagoscopes  of  the  sizes  he  has  standardized  for  all 
ordinary  requirements.  He  uses  various  other  lengths  and  sizes  for  special  purposes, 
but  none  of  them  are  really  necessary.  A  gastroscope,  10  mm.  X  70  cm.,  is  useful 
for  adults,  especially  in  cases  of  gastroptosis.  Drainage  canals  are  placed  at  the  top 
or  at  the  side  of  the  tube,  next  to  the  light-carrier  canal. 

A,  Adult's  size,  10  mm.  X  53  cm.;  B,  child's  size,  7  mm.  X  45  cm.;  C  and  D,  full 
lumen,  with  both  light  canal  and  drainage  canal  outside  the  wall  of  the  tube,  to  be 
used  for  passing  very  large  bougies.  This  instrument  is  made  in  adult,  child,  and 
adolescent  (8  mm.  by  45  cm.)  sizes.  Gastroscopes  and  esophagoscopes  of  the  sizes 
given  above  (A)  and  (B),  can  be  used  also  as  gastroscopes.  A  small  form  of  C,  5  mm. 
X  30  cm.  is  used  in  infants,  and  also  as  a  retrograde  esophagoscope  in  patients  of  any 
age.     E,  window  plug  for  ballooning  gastroscope,  F. 

phagoscopes  (Fig.  5)  are  made  with  both  light  canal  and  drainage 
canal  outside  the  lumen  of  the  tube,  leaving  the  full  area  of  lum- 
inal cross-section  unencroached  upon.  They  can,  of  course,  be 
used  for  all  purposes,  but  the  slightly  greater  circumference  is  at 


IXSTRUMEXTARIUM 


23 


times  a  disadvantage.  The  esophageal  and  stomach  secretions 
are  much  thinner  than  bronchial  secretions,  and,  if  free  from  food, 
are  readily  aspirated  through  a  comparatively  small  canal.     If 


A 


^m 


Tk 


I 


Fig.  4. — Author's  short  esophagoscopes  and  esophageal  specula 
A,  Esophageal  speculum  and  hjqjopharyngoscope,  adult's  size;   B,  esophageal 
speculum  and  hypopharyngoscope,  child's  size;  C,  heavy  handled  short  esophago- 
scope;  D,  heavy  handled  short  esophagoscope  with  drainage. 

the  canal  becomes  obstructed  during  esophagoscopy,  the  positive 
pressure  tube  of  the  aspirator  is  used  to  blow  out  the  obstruction. 
Two  sizes  of  esophagoscopes  are  all  that  are  required — 7  mm.  X 
45  cm.  for  children,  and  10  mm.  X  53  cm.  for  adults  (Fig.  3,  A 
and  B) ;  but  various  other  sizes  and  lengths  are  used  by  the  author 


24  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

for  special  purposes.*  Large  esophagoscopes  cause  dangerous 
dyspnea  in  children.  If,  it  is  desired  to  balloon  the  esophagus  with 
air,  the  window  plug  shown  in  Fig.  6,  is  inserted  into  the  proximal 
end  of  the  esophagoscope,  and  air  insuf- 
flated by  means  of  the  positive  pressure 
'men  of  the  hand  aspirator    or    with    a   hand 

^i\§|Dirat I ng  canal     bulb.     The  window  can  be  replaced  by  a 
rubber  diaphragm  with  a  perforation  for 

Fig    5. — Cross    section  x         cj 

of  full-lumen  esophagoscope    forceps  if  desired.     It  will  be  noted  that 
for  the  use  of  largest  bou-    ^^^^  ^f  ^^^  endoscopic  tubes  are  fitted 

gies.      The   canals  for  the 

light  carrier  and  for  drain-    with  mandrins.     They  are   to   be   intro- 

age  are  so  constructed  that      ^^^^^   ^^^^^    ^^^   ^jj.^^,^   guidance    of    the 
they  do  not  encroach  upon 

the  lumen  of  the  tube.  eye  only.     Mandrins  are  obtainable,  but 

their  use  is  objectionable  for  a  number  of 
reasons,  chief  of  which  is  the  danger  of  overriding  a  foreign  body 
or  a  lesion,  or  of  perforating  a  lesion,  or  even  the  normal  esophageal 
wall.  The  slanted  end  on  the  esophagoscope  obviates  the  necessity 
of  a  mandrin  for  introduction.  The  longer  the  slant,  with  conse- 
quent acuting  of  the  angle,  the  more  the  introduction  is  facilitated ; 
but  too  acute  an  angle  increases  the  risk  of  perforating  the  esopha- 
geal wall,  and  necessitates  the  utmost  caution.  In  some  foreign- 
body  cases  an  acute  angle  giving  a  long  slant  is  useful,  in  others  a 
short  slant  is  better,  and  in  a  few  cases  the  squarely  cut-off  distal  end 
is  best.  To  have  all  of  these  different  slants  on  hand  would  require 
too  many  tubes.  Therefore  the  author  has  settled  upon  a  moder- 
ate angle  for  the  end  of  both  esophagoscopes  and  bronchoscopes 
that  is  easy  to  insert,  and  serves  all  purposes  in  the  version  and 
other  manipulations  required  by  the  various  mechanical  problems 
of  foreign-body  extraction.  He  has,  however,  retained  all  the 
experimental  models,  for  occasional  use  in  such  cases  as  he  falls 
heir  to  because  of  a  problem  of  extraordinary  difficulty. 

*  A  9  mm.  X  45  cm.  esophagoscope  will  reach  the  stomach  of  almost  all  adults 
and  is  somewhat  easier  to  introduce  than  the  10  mm.  X  53  cm.,  which  may  be 
omitted  from  the  set  if  economy  must  be  practiced. 


INSTRUMENTARIUM  2$ 

The  special  sized  esophagoscopes  most  often  useful  are  the 
8  mm.  X  30  cm.,  the  8  mm.  X  45  cm.,  and  the  5  mm.  X  45  cm. 
These  are  made  with  the  drainage  canal  in  various  positions. 

For  operations  on  the  upper  end  of  the  esophagus,  and  particu- 
larly for  foreign  body  work,  the  esophageal  speculum  shown  at 
A  and  B,  in  Fig.  4,  is  of  the  greatest  service.  With  it,  the  anterior 
wall  of  the  post-cricoidal  pharynx  is  lifted  forward,  and  the  upper 
esophageal  orifice  exposed.  It  can  then  be  inserted  deeper,  and 
the  upper  third  of  the  esophagus  can  be  explored.     Two  sizes  are 


Rubber. 
dldplnmgm 

Fig.  6. — Window-plug  with  glass  cap  interchangeable  with  a  cap  having  a  rubber 
diaphragm  with  a  perforation  so  that  forceps  may  be  used  without  allowing  air  to 
escape.     Valves  on  the  canals  (E,  F,  Fig.  3)  are  preferable. 

made,  the  adult's  and  the  child's  size.  These  instruments  serve, 
very  efficiently  as  pleuroscopes.  They  are  made  with  and  without 
drainage  canals,  the  latter  being  the  more  useful  form. 

Gastroscopes. — The  gastroscope  is  of  the  same  construction  as 
the  esophagoscope,  with  the  exception  that  it  is  made  longer,  in 
order  to  reach  all  parts  of  the  stomach.  In  ordinary  cases,  the 
regular  esophagoscopes  for  adults  and  children  respectively  will 
afford  a  good  view  of  the  stomach,  but  there  are  cases  which  re- 
quire longer  tubes,  and  for  these  a  gastroscope  10  mm.  X  70  cm. 
is  made,  and  also  one  10  mm.  X  80  cm.,  though  the  latter  has 
never  been  needed  but  once. 


2  6  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

Pleuroscopes. — As  mentioned  above  the  anterior  commissure 
laryngoscope  and  the  esophageal  specula  make  very  efficient 
pleuroscopes;  but  three  different  forms  of  pleuroscopes  have  been 
devised  by  the  author  for  pleuroscopy.  The  retrograde  esopha- 
goscope  serves  very  well  for  work  through  small  fistulae. 

Measuring  Rule  (Fig.  7). — It  is  customary  to  locate  esophageal 
lesions  by  denoting  their  distance  from  the  incisor  teeth.  This 
is  readily  done  by  measuring  the  distance  from  the  proximal  end 
of  the  esophagoscope  to  the  upper  incisor  teeth,  or  in  their  absence, 


Fig.  7. — Measuring  rule  for  gauging  in  centimeters  the  depth  of  any  location  by 
subtraction  of  the  length  of  the  uninserted  portion  of  the  esophagoscope  or  broncho- 
scope. This  is  preferable  to  graduations  marked  on  the  tubes,  though  the  tubes 
can  be  marked  with  a  scale  if  desired. 

to  the  upper  alveolar  process,  and  subtracting  this  measurement 
from  the  known  length  of  the  tube.  Thus,  if  an  esophagoscope 
45  cm.  long  be  introduced  and  we  find  that  the  distance  from  the 
incisor  teeth  to  the  ocular  end  of  the  esophagoscope  as  measured 
by  the  rule  is  20  cm.^  we  subtract  this  20  cm.  from  the  total  length 
of  the  esophagoscope  (45  cm.)  and  then  know  that  the  distal  end 
of  the  tube  is  25  cm.  from  the  incisor  teeth.  Graduation  marks 
on  the  tube  have  been  used,  but  are  objectionable. 

Batteries. — The  simplest,  best,  and  safest  source  of  current  is 
a  double  dry  battery  arranged  in  three  groups  of  two  cells  each, 
connected  in  series  (Fig.  8).  Each  set  should  have  two  binding 
posts  and  a  rheostat.  The  binding  posts  should  have  double  holes 
for  two  additional  cords,  to  be  kept  in  reserve  for  use  in  case  a  cord 
becomes  defective.*  The  commercial  current  reduced  through 
a  rheostat  should  never  be  used,  because  there  is  always  the  possi- 
bility of  "grounding"  the  circuit  through  the  patient;  a  highly 
dangerous  accident  when  we  consider  that  the  tube  makes  a  long 

*  When  this  is  done  care  is  necessary  to  avoid  attempting  to  use  simultaneously 
the  two  cords  from  one  pair  of  posts. 


INSTRUMENTARIUM 


27 


moist  contact  in  tissues  close  to  the  course  of  both  the  vagi  and 
the  heart.  The  endoscopist  should  never  depend  upon  a  pocket 
battery  as  a  source  of  illumination,  for  it  is  almost  certain  to  fail 
during  the  endoscopy.  The  wires  connecting  the  battery  and 
endoscopic  instrument  are  covered  with  rubber,  so  that  they 
may  be  cleansed  and  superficially  sterilized  with  alcohol.     They 


Fig  8. — The  author's  endoscopic  battery,  heavily  built  for  reliability.  It 
contains  6  dry  cells,  series-connected  in  3  groups  of  2  cells  each.  Each  group  has  its 
own  rheostat  and  pair  of  binding  posts. 

may  be  totally  immersed  in  alcohol  for  any  length  of  time  without 
injury. 

Aspirating  Tubes. — Independent  aspirating  tubes  involve 
delay  in  their  use  as  compared  to  aspirating  canals  in  the  wall  of 
the  endoscopic  tube;  but  there  are  special  cases  in  which  an  inde- 
pendent tube  is  invaluable.  Three  forms  are  used  by  the  author. 
The  "velvet  eye"  cannot  traumatize  the  mucosa  (Fig.  9).  To 
hold  a  foreign  body  by  suction,  a  squarely  cut  off  end  is  necessary. 
For  use  through  the  tracheotomic  wound  without  a  bronchoscope 
a  malleable  tube  (Fig.  10)  is  better. 


25  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

Aspirators. — The  various  electric  aspirators  so  universally  used 
in  throat  operations  should  be  utilized  to  withdraw  secretions  in 


"S^ 


(ubber 
.  ;  tube  to 
@;TnechaniCfll    asjairaton 

Fig.  9. — The  author's  protected-aperture  endoscopic  aspirating  tube  for  aspira- 
tion of  pharyngeal  secretions  during  direct  laryngoscopy  and  endotracheobronchial 
secretions  at  bronchoscopy;  also  for  draining  retropharyngeal  abscesses.  The 
laryngoscopes  are  obtainable  with  drainage  canals,  but  for  most  purposes  the 
independent  aspirating  tube  shown  above  is  more  satisfactory.  The  tubes  are  made 
in  20  30,  40,  and  60  cm.  lengths.  An  aperture  on  both  sides  prevents  drawing 
in  the  mucosa.  It  can  be  used  for  insufflation  of  ether  if  desired.  An  aspirating  tube 
of  the  same  design,  but  having  a  squarely  cut  off  end,  is  sometimes  useful  for  remov- 
ing secretions  lying  close  to  a  foreign  body;  for  removing  papilloma ta;  and  even  for 
withdrawing  foreign  bodies  of  a  soft  surface  consistency.  It  is  not  often  that  the 
foreign  bodies  can  be  thus  withdrawn  through  the  glottis,  but  closely  fitting  foreign 
bodies  can  at  least  be  withdrawn  to  a  higher  level  at  which  ample  forceps  spaces  will 
permit  application  of  forceps.  Such  aspirating  tubes,  however,  are  not  so  safe  to  use 
as  the  protected,  double  aperture  tubes. 


Fig.  10. — The  author's  malleable  tracheotomic  aspirating  tube  for  removal  of 
secretions,  exudates,  crusts,  etc.,  from  the  tracheobronchial  tree  through  the 
tracheotomic  wound  without  a  bronchoscope.  The  tube  is  made  of  copper  so  that  it 
can  be  bent  to  any  curve,  and  the  copper  wire  stylet  prevents  kinking.  The  stylet 
is  removed  before  using  the  tube  for  aspiration. 

the  tubes  fitted  with  drainage  canals.  They,  however,  have  the 
disadvantages  of  not  being  easily  transported,  and  of  occasionally 
being  out  of  order.     The  hand  aspirator  shown  in  Fig.  11  is,  there- 


INSTRUMENTARIUM  29 

fore,  a  necessary  part'  of  the  instrumental  equipment.     It  never 
fails  to  work,  is  portable,  and  affords  both  positive  and  negative 


Fig.  1 1  — Portable  aspirator  for  endoscopy  with  additional  tube  connected  with 
the  plus  pressure  side  for  use  in  case  of  occlusion  of  the  drainage  canal.  This 
aspirator  has  the  advantage  of  great  power  with  portability.  Where  portability  is 
not  required  the  electrically  operated  aspirator  is  better. 


Fig.  13. — Apparatus  for  insufflation  of  ether  or 
chloroform  during  bronchoscopy,  for  those  who  may 
desire  to  use  general  anesthesia.  The  mechanical 
methods  of  intratracheal  insufflation  anesthesia  sub- 
sequently developed  by  Meltzer  and  Auer,  Elsberg, 
Geo.  P.  Muller  and  others  have  rightly  superseded 
this  apparatus  for  all  general  surgical  purposes. 


Fig.  12. — Robin- 
son mechanical  aspi- 
rator adapted  for 
bronchoscopic  and 
esophagoscopic  aspi- 
ration by  the  author. 
The  positive  pressure 
is  used  for  clearing 
obstructed  drainage 
canals  and  tubes. 


pressures.  The  positive  pressure  is  sometimes  useful  in  clearing 
the  drainage  canal  of  any  particles  of  food,  tissue,  clots,  or  secre- 
tion which  may  obstruct  it;  and  it  also  serves  to  fill  the  stomach  or 


30 


BRONCHOSCOPY  AND  ESOPHAGOSCOPY 


esophagus  with  air  when  the  ballooning  procedure  is  used.  The 
mechanical  aspirator  (Fig.  12)  is  highly  efficient  and  is  the  one  used 
in  the  Bronchoscopic  Clinic.  The  positive  pressure  will  quickly- 
clear  obstructed  drainage  canals,  and  may  be  used  while  the 
esophagoscope  is  in  situ,  by  simply  detaching  the  minus  pressure 
tube  and  attaching  the  plus  pressure.  In  the  lungs,  however,  high 
plus  pressures  are  so  dangerous  that  the  pressure  valve  must  be 
lowered. 

Sponge- pumping. — While  the  usually  thin,  watery  esophageal 


Fig.  14. — Sponge  carrier  with  long  collar  for  carrying  the  small  sponges  shown  in 
Fig.  15.  The  collar  screws  down  as  in  the  Coolidge  cotton  carrier.  '  About  a  dozen. 
of  these  are  needed  and  they  should  all  be  small  enough  to  go  through  the  4  mm. 
(diameter)  bronchoscope  and  long  enough  to  reach  through  the  53  cm.  (length) 
esophagoscope,  so  that  one  set  will  do  for  all  tubes.  The  schema  shows  method  of 
sponging.  The  carrier  C,  armed  with  the  sponge,  S,  when  rotated  as  shown  by  the 
dart,  D,  wipes  the  field,  P,  at  the  same  time  wiping  the  lamp,  L.  The  lamp  does  not 
need  ever  to  be  withdrawn  for  cleaning  during  bronchoscopy.  It  is  protected  in  a 
recess  so  that  it  does  not  catch  in  the  sponges. 

and  gastric  secretions,  if  free  from  food,  are  readily  aspirated 
through  a  drainage  canal,  the  secretions  of  the  bronchi  are  often 
thick  and  mucilaginous  and  aspirated  with  difficulty.  Further- 
more, bronchial  secretions  as  a  rule  are  not  collected  in  pools,, 
but  are  distributed  over  the  walls  of  the  larger  bronchi  and 


INSTRUMEXTARIUM 


31 


continuously  well  up  from  smaller  bronchi  during  cough.  The 
aspirating  bronchoscopes  should  be  used  whenever  their  very 
slight  additional  area  of  cross-section  is  unobjectionable.  In 
most   cases,   however,   the  most  advantageous  way   to  remove 


...  A  ..., 

tl'B 

4  mm. 

5 

7 

9cina  10 

Tubts. 

Fig  15.- — Exact  size  to  which  the  bandage-gauze  is  cut  to  make  endoscopic 
sponges.  Each  rectangle  is  the  size  for  the  tubal  diameter  given.  The  dimen- 
sions of  the  respective  rectangles  are  not  given  because  it  is  easier  for  the  nurse  or 
any  one  to  cut  a  cardboard  pattern  of  each  size  directly  from  this  drawing.  The 
gauze  rectangles  are  folded  up  endwise  as  shown  at  A,  then  once  in  the  middle  as  at 
B,  then  strung  one  dozen  on  a  safety  pin.  In  America  gauze  bandages  run  about  16 
threads  to  the  centimeter.  Different  material  might  require  a  slightly  different 
size  and  the  pattern  could  be  made  to  suit. 

bronchial  secretion  has  been  found  to  be  by  introducing  a  gauze 
swab  on  a  long  sponge  carrier  (Fig.  14),  so  that  the  sponge  extends 
beyond  the  distal  end  of  the  bronchoscope,  causing  cough.  Then 
withdrawal  of  the  sponge  carrier  will  remove  all  of  the  secretion  in 
the  tube  just  as  the  plunger  in  a  pump  will  lift  all  of  the  water 
above  it.  By  this  maneuver  the  walls  of  the  bronchus  are  wiped 
free  from  secretions,  and  the  lamp  itself  is  cleansed. 


32 


BRONCHOSCOPY  AND  ESOPHAGOSCOPY 


The  gauze  sponges  are  made  by  the  instrument  nurse  as 
directed  in  Fig.  15,  and  are  strung  on  safety  pins,  wrapped  in 
paper,  the  size  indicated  by  a  figure  on  the  wrapper,  and  then 
steriHzed  in  an  autoclave.  The  sterile  packages  are  opened  only 
as  needed .  These ' '  bronchoscopic  sponges ' ' 
are  also  made  by  Johnston  and  Johnston, 
of  New  Brunswick,  N.  J.  and  are  sold  in 
the  shops. 

Mouth-gag. — Wide  gagging  prevents 
proper  exposure  of  the  larynx  by  forcing 
the  mandible  down  on  the  hyoid  bone. 
The  mouth  should  be  gently  opened  and  a 
bite  block  (Fig.  16)  inserted  between  the 
teeth  on  the  left  side  of  the  patient's  mouth, 
to  prevent  closing  of  the  jaws  on  the  deli- 
cate bronchoscope  or  esophagoscope. 

Forceps. — DeKcacy  of  touch  and  manipu- 
lation   are    an    absolute    necessity    if    the 
endoscopist  is  to  avoid  mortaHty;  therefore,   heavily  built  and 


Fig.  16. — Bite  block 
to  be  inserted  between 
the  teeth  to  prevent 
closure  of  the  jaws  on 
the  endoscopic  tube. 
This  is  the  McKee- 
McCready  modification 
of  the  Boyce  thimble 
with  the  omission  of  the 
etherizing  tube,  which  is 
no  longer  needed.  The 
block  has  been  improved 
by  Dr.  W.  F.  Moore  of 
the  Bronchoscopic  Clinic. 


Fig.  17. — ^Laryngeal  grasping  forceps  designed  by  Mosher.  For  my  own  use  I 
have  taken  off  the  ratchet-locking  device  for  all  general  work,  to  be  reapplied  on  the 
rare  occasions  when  it  is  required. 


spring-opposed   forceps   are   dangerous  as  well  as  useless.     For 
foreign-body  work  in  the  larynx,  and  for  the  removal  of  benign 


INSTRUMENTARIUM  33 

laryngeal  growths,  the  alligator    forceps   with  roughened    jaws 
shown  in  Fig.  17  serve  every  purpose. 

Bronchoscopic  and  esophagoscopic  grasping  forceps  are  of  the 
tubular  type,  that  is,  a  stylet  carrying  the  jaws  works  in  a  slender 
tube  so  that  traction  on  the  stylet  draws  the  V  of  the  open  jaws 
into  the  lumen  of  the  tube,  thus  causing  the  blades  to  approxi- 


FiG.  18. — The  author's  forward  grasping  tube  forceps.  The  handle  mechanism 
is  so  simple  and  delicate  that  the  most  exquisite  delicacy  of  touch  is  possible.  Two 
locknuts  and  a  thumbscrew  take  up  all  lost  motion  yet  aflford  perfect  adjustability 
and  easy  separation  for  cleansing.  At  A  is  shown  a  small  clip  for  keeping  the  jaws 
together  to  prevent  injurious  bending  in  the  sterilizer,  or  carrying  case.  At  the  left 
is  shown  a  handle-clamp  for  locking  the  forceps  on  a  foreign  body  in  the  solution  of 
certain  rarely  encountered  riiechanical  problems.     The  jaws  are  serrated  and  cupped. 

mate.  They  are  very  deUcate  and  light,  yet  have  great  grasping 
power  and  will  sustain  any  degree  of  traction  that  it  is  safe  to 
exert.  They  permit  of  the  delicacy  of  touch  of  a  violin  bow. 
The  two  types  of  jaws  most  frequently  used,  are  those  with  the 
forward-grasping  blades  shown  in  Fig.  18,  and  those  having 
side-grasping  blades  shown  in  Fig.  19.  The  side-curved  forceps 
are  perhaps  the  most  generally  useful  of  all  the  endoscopic  for- 
ceps; the  side  projection  of  the  jaws  makes  them  readily  visible 
during  their  closure  on  an  object;  their  broader  grasp  is  also  an 


34 


BRONCHOSCOPY  AND  ESOPHAGOSCOPY 


advantage.  The  projection  of  the  blades  in  the  side-curved 
grasping  forceps  should  always  be  directed  toward  the  left.  If 
it  is  desired  that  they  open  in  another  direction  this  should  be 

accomplished  by  turning  the  handle 
and  not  by  adjusting  the  blade  itself. 
If  this  rule  be  followed  it  will  always 
be  possible  to  tell  by  the  position  of 
the  handle  exactly  where  the  blades 
are  situated;  whereas,  if  the  jaws 
themselves  are  turned,  confusion  is 
sure  to  result.     The  forward-grasp- 


FiG.  19. — Jaws  of  the  author's 
side-curved  endoscopic  forceps. 
These  work  as  shown  in  the  pre- 
ceding illustration^  each  forceps 
having  its  own  handle  and  tube. 
Originally  the  end  of  the  cannula 
and  stylet  were  squared  to  pre- 


vent rotation  of  the  jaws  in  the 

cannula.    This  was  found  to  be     ing  forceps  are   always  SO  adjusted 

unnecessary  with  properly  shaped  ^^^^  ^^le  jaws  open  in  an  up-and- 
jawS;  which  wedge  tightly. 

down  direction.  On  rare  occasions 
it  may  be  deemed  desirable  to  turn  the  stylet  of  either  forceps 
in  some  other  direction  relative  to  the  handle. 

Rotation  Forceps. — It  is  sometimes  desired  to  make  traction  on 
an  irregularly  shaped  foreign  body,  and  yet  to  allow  the  object 
to  turn  into  the  line  of  least  resistance  while  traction  is  being  made. 
This  can  be  accompHshed  by  the  use  of 
the  rotation  forceps  (Fig.  20),  which  have 
for  blades  two  pointed  hooks  that  meet 
at  their  points  and  do  not  overlap. 
Rotation  forceps  made  on  the  model  of 
the  laryngeal  grasping  forceps,  but  hav- 
ing opposing  points  at  the  end  of  the 
blades,  are  sometimes  very  useful  for 
the  removal  of  irregular  foreign  bodies 
in  the  larynx,  or  when  used  through  the 

esophageal  speculum  they  are  of  great  service  in  the  extraction 
of  such  objects  as  bones,  pin-buttons,  and  tooth-plates,  from  the 
upper  esophagus.     These  forceps  are  termed  laryngeal  rotation 


Fig.  20. — The  author's 
rotation  forceps.  Useful  to 
allow  turning  of  an  irregular 
foreign  body  to  a  safer  rela- 
tion for  withdrawal  and  for 
the  esophagoscopic  removal 
of  safety  pins  by  the  method 
of  pushing  them  into  the 
stomach,  turning  and  with- 
drawal, spring  up. 


INSTRUMENTARIUM 


35 


forceps  (Fig.  31).  All  the  various  forms  of  forceps  are  made  in 
a  very  delicate  size  often  called  the  "mosquito"  or  "extra  light" 
forceps,  40  cm.  in  length,  for  use  in  the  4  mm.  and  the  5  mm. 
bronchoscopes.  For  the  5  mm.  bronchoscopes  heavier  forceps 
of  the  40  cm.  length  are  made.     For  the         ---->,  ..  --. 

larger  tubes  the  forceps  are  made  in  45 
cm.,  50  cm.  and  60  cm.  lengths.  A  square- 
cannula  forceps  to  prevent  turning  of  the 
jaws  was  at  one  time  used  by  the  author 
but  it  has  since  been  found  that  the  round 
cannula  pattern  serves  all  purposes. 

Upper-lobe-bronchus  Forceps. — Foreign 
bodies  rarely  lodge  in  an  upper-lobe 
bronchus,  yet  with  such  a  problem  it  is 
necessary  to  have  forceps  that  will  reach 
around  a  corner.  The  upper-lobe-bron- 
chus forceps  shown  in  Fig.  27  have  curved 
jaws,  so  made  as  to  straighten  out  while 
passing  through  the  bronchoscope  and  to 
spring  back  into  their  original  shape  on 
emerging  from  the  distal  end  of  the 
bronchoscopic  tube,  the  radius  of  curva- 
ture being  regulated  by  the  extent  of 
emergence  permitted.  They  are  made  in 
an  extra-light  pattern,  40  cm.  long,  and 
the  regular  model  45  cm.  long.  The  full-curved  model,  giving  180 
degrees  and  reaching  up  into  the  ascending  branches,  is  made  in 
both  light  and  heavy  patterns.  Forceps  with  less  curve,  and 
without  the  spiral,  are  used  when  it  is  desired  to  reach  only  a  short 
distance  "around  the  corner"  anywhere  in  the  bronchi.  These 
are  also  useful,  as  suggested  by  Willis  F.  Manges,  in  dealing  with 
safety  pins  in  the  esophagus  or  tracheobronchial  tree. 


Fig.  21. — Tucker  jaws 
for  the  author's  forceps. 
The  tiny  lip  projecting 
down  from  the  upper,  and 
up  from  the  lower  jaw 
prevents  side  wise  escape 
of  the  shaft  of  a  pin,  tack, 
nail  or  needle.  The  shaft 
is  automatically  thrown 
parallel  to  the  broncho- 
scopic axis.  Drawing  about 
four  times  actual  size. 


36 


BRONCHOSCOPY  AND  ESOPHAGOSCOPY 


Tucker  Forceps. — Gabriel  Tucker  modified  the  regular  side- 
curved  forceps  by  adding  a  lip  (Fig.  21)  to  the  left  hand  side  of 
both  upper  and  lower  jaws.  This  prevents  the  shaft  of  a  tack, 
nail,  or  pin,  from  springing  out  of  the  grasp  of  the  jaws,  and  is  so 


Fig.  22. — The  author's  down- jaw  esophageal  forceps.  The  dropping  jaw  is  use- 
ful for  reaching  backward  below  the  cricopharyngeal  fold  when  using  the  esopha- 
geal speculum  in  the  removal  of  foreign  bodies.  Posterior  forceps-spaces  are  often 
scanty  in  cases  of  foreign  bodies  lodged  just  below  the  cricopharyngeus. 


U— -^ 


Fig.  23. — Expansile  forceps  for  the  endoscopic  removal  of  hollow  foreign  bodies 
such  as  intubation  tubes,  tracheal  cannulae,  caps,  and  cartridge  shells. 


efficient  that  it  has  brought  certainty  of  grasp  never  biefore  obtain- 
able. With  it  the  solution  of  the  safety-pin  problem  devised  by 
the  author  many  years  ago  has  a  facility  and  certainty  of  execu- 
tion that  makes  it  the  method  of  choice  in  safety-pin  extraction. 

Screw-forceps. — For  the  secure  grasp  of  screws  the  jaws 
devised  by  Dr.  Tucker  for  tacks  and  pins  are  excellent  (Fig.  21). 

Expanding  Forceps. — Hollow  objects  may  require  expanding 
forceps  as  shown  in  Fig.  23.  In  using  them  it  is  necessary  to  be 
certain  that  the  jaws  are  inside  the  hollow  body  before  expanding 


INSTRUMENTARIUM 


37 


them  and  making  traction.     Otherwise  severe,  even  fatal,  trauma 
may  be  inflicted. 


Fig.  24.^ — The  author's  fenestrated  peanut  forceps.  The  dehcate  construction 
with  long,  springy  and  fenestrated  jaws  give  in  gentle  hands  a  maximum  security 
with  a  minimum  of  crushing  tendency. 


Fig.  25 — The  author's  bronchial  dilators,  useful  for  dilating  strictures  above 
foreign  bodies.  The  smaller  size,  shown  at  the  right  is  also  useful  as  an  expanding 
forceps  for  removing  intubation  tubes,  and  other  hollow  objects.  The  larger  size 
will  go  over  the  shaft  of  a  tack. 


^: 


Fig.  26. — The  author's  self-expanding  bronchial  dilator.  The  extent  of  expan- 
sion can  be  limited  by  the  sense  of  touch  or  by  an  adjustable  checking  mechanism  on 
the  handle.  The  author  frequently  used  smooth  forceps  for  this  purpose,  and 
found  them  so  efficient  that  this  dilator  was  devised.  The  edges  of  forceps  jaws 
are  Ukely  to  scratch  the  epithehum.  Occasionally  the  instrument  is  useful  in 
the  esophagus;  but  it  is  not  very  safe,  unless  used  with  the  utmost  caution. 

Tissue  Forceps.— With,  the  forceps  illustrated  in  Fig.  28 
specimens  of  tissue  may  be  removed  for  biopsy  from  the  lower 
air  and  food  passages  with  ease  and  certainty.     They  have  a 


38 


BRONCHOSCOPY  AND  ESOPHAGOSCOPY 


cross  in  the  outer  blade  which  holds  the  specimen  removed.     The 
action  is  very  dehcate,  there  being  no  springs,  and  the  sense  of 


Fig.  27. — The  author's  upper- lobe  bronchus  forceps.  At  J  is  shown  the  full- 
curved  form,  for  reaching  into  the  ascending  branches  of  the  upper-lobe  bronchus 
A  number  of  different  forms  of  jaws  are  made  in  this  kind  of  forceps.  Only  2  are 
shown. 


Fig  28. — The  author's  endoscopic  tissue  forceps.  The  laryngeal  length  is  30 
cm.  For  esophageal  use  they  are  made  50  and  60  cm.  long.  These  are  the  best  for- 
ceps for  cutting  out  small  specimens  of  tissue  for  biopsy. 

touch  imparted  is  often  of  great  aid  in  the  diagnosis. 

The  large  basket  punch  forceps  shown  in  Fig.  ^^  are  useful 
in  removing  larger  growths  or  specimens  of  tissue  from  the  pharynx 


IXSTRUMEXTARIUM 


39 


or  larynx.  A  portion  or  the  whole  of  the  epiglottis  may  be  easily 
and  quickly  removed  with  these  forceps,  the  laryngoscope  intro- 
duced along  the  dorsum  of  the  tongue  into  the  glossoepiglottic 


Fig.  29  — The  author's  papilloma  forceps.  The  broad  blunt  nose  will  scalp  off 
the  growths  without  any  injury  to  the  normal  basal  tissues.  Voice-destroying  and 
stenosing  trauma  are  thus  easily  avoided. 


Fig.  30 — The  author's  short  mechanical  spoon  (30  cm.  long). 

recess,  bringing  the  whole  epiglottis  into  view.  The  forceps  may 
be  introduced  through  the  laryngoscope  or  alongside  the  tube.  In 
the  latter  method  a  greater  lateral  action  of  the  forceps  is  obtain- 
able, the  tube  being  used  for  vision  only.  These  forceps  are  30 
cm.  long  and  are  made  in  two  sizes;  one  with  the  punch  of  the 
largest  size  that  can  be  passed  through  the  adult  laryngoscope, 


40  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

and  a  smaller  one  for  use  through  the  anterior-commissure  laryn- 
goscope and  the  child's  size  laryngoscope. 

Papilloma  Forceps. — Papillomata  do  not  infiltrate;  but  super- 
ficial repullulations  in  many  cases  require  repeated  removals. 
If  the  basal  tissues  are  traumatized,  an  impaired  or  ruined  voice 


•30  cm 


Fig.  31  — The  author's  laryngeal  rotation  forceps. 


Fig.  32.  Fig.  7,3. 

Fig.  32.^ — Enlarged  view  of  the  jaws  of  the  author's  vocal-nodule  forceps.  Larger 
cups  are  made  for  other  purposes  but  these  tiny  cups  permit  of  that  extreme  delicacy 
required  in  the  excision  of  the  nodules  from  the  vocal  cords  of  singers  and  other 
voice  users. 

Fig  33. — Extra  large  laryngeal  tissue  forceps,  30  cm.  long,  for  removing  entire 
growths  or  large  specimens  of  tissue.     A  smaller  size  is  made. 

will   result.     The   author   designed   these   forceps    (Fig.    29)    to 
scalp  off  the  growths  without  injury  to  the  normal  tissues. 

Bronchial  Dilators. — It  is  not  uncommon  to  find  a  stricture 
of  the  bronchus  superjacent  to  a  foreign  body  that  has  been  in 
situ  for  a  period  of  months.  In  order  to  remove  the  foreign  body, 
this  stricture  must  be  dilated,  and  for  this  the  bronchial  dilator 
shown  in  Fig.  25  was  devised.  The  channel  in  each  blade  allows 
the  closed  dilator  to  be  pushed  down  over  the  presenting  point  of 
such  bodies  as  tacks,  after  which  the  blades  are  opened  and  the 
stricture  stretched.     A  small  and  a  large  size  are  made.     For 


INSTRUMENTARIUM 


41 


Zf  CM.. 


Fig.  34. — A,  Mosher's  laryngeal  curette;  B,  author's  flat  blade  cautery  electrode; 
C,  pointed  cautery  electrode;  D,  laryngeal  knife.  The  electrodes  are  insulated  with 
hard-rubber  vulcanized  onto  the  conducting  wires. 


^"^rdided  silk  -  continuous- 


-Soft  rubier 


Fig.  35. — Retrograde  esophageal  bougies  in  graduated  sizes  devised  by  Dr. 
Gabriel  Tucker  and  the  author  for  dilatation  of  cicatricial  esophageal  stenosis. 
They  are  drawn  upward  by  an  endless  swallowed  string,  and  are  therefore  only  to  be 
used  in  gastrostomized  cases. 


42  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

enlarging  the  bronchial  narrowing  associated  with  pulmonary- 
abscess  and  sometimes  found  above  a  bronchiectatic  or  foreign 
body  cavity,  the  expanding  dilator  shown  in  Fig.  26  is  perhaps 


// 


V 


Fig.  36. — Author's  bronchoscopic  and  esophagoscopic  mechanical  spoon,  made  in 
40,  50  and  60  cm.  lengths. 


>H 


L 


Fig.  3  7. — Schema  illustrating  the  author's  method  of  endoscopic  closure  of  open 
safety  pins  lodged  point  upward  The  closer  is  passed  down  under  ocular  contrdl 
until  the  ring,  R,  is  below  the  pin.  The  ring  is  then  erected  to  the  position  shown 
dotted  at  M,  by  moving  the  handle,  H^  downward  to  L  and  locking  it  there  with  the 
latch,  Z.  The  fork,  A,  is  then  inserted  and,  engaging  the  pin  at  the  spring  loop,  K, 
the  pin  is  pushed  into  the  ring,  thus  closing  the  pin.  Slight  rotation  of  the  pin  with 
the  forceps  may  be  necessary  to  get  the  point  into  the  keeper.  The  upper  instru- 
ment is  sometimes  useful  as  a  mechanical  spoon  for  removing  large,  smooth  foreign 
bodies  from  the  esophagus. 

less  apt  to  cause  injury  than  ordinary  forceps  used  in  the  same  way. 
The  stretching  is  here  produced  by  the  spring  of  the  blades  of  the 
forceps  and  not  by  manual  force.  The  closed  blades  are  to  be 
inserted  through  the  strictured  area,  opened,  and  then  slowly 
withdrawn.     For  cicatricial  stenoses  of  the  trachea  the  metallic 


IXSTRUMEXTARIUM  43 

bougies,  Fig.  40,  are  useful.     For  the  larynx,  those  shown  in  Fig. 
41  are  needed. 

Esophageal  Dilators. — The  dilatation  of  cicatricial  stenosis 
of  the  esophagus  can  be  done  safely  only  by  endoscopic  methods. 
Blind  esophageal  bouginage  is  highly  dangerous,  for  the  lumen 
of  the  stricture  is  usually  eccentric  and  the  bougie  is  therefore 
apt  to  perforate  the  wall  rather  than  find  the  small  opening. 
Often  there  is  present  a  pouching  of  the  esophagus  above  a  stric- 
ture, in  which  the  bougie  may  lodge  and  perforate.  Bougies 
should  be  introduced  under  visual  guidance  through  the  esophago- 


J 


Fig  38. — Half  cur\'ed  hook,  45  cm.  and  60  cm^  Full  curved  patterns  are  made 
but  caution  is  necessary  to  avoid  them  becoming  anchored  in  the  bronchi  Spiral 
forms  avoid  this.  The  author  makes  for  himself  steel  probe-pointed  rods  out  of 
which  he  bends  hooks  of  any  desired  shape.  The  rod  is  held  in  a  pin-vise  to  facili- 
tate bending  of  the  point,  after  heating  in  an  alcohol  or  bunsen  flame. 

scope,  which  is  so  placed  that  the  lumen  of  the  stricture  is  in  the 
center  of  the  endoscopic  field.  The  author's  endoscopic  bougies 
(Fig.  40)  are  made  with  a  flexible  silk-woven  tip  securely  fastened 
to  a  steel  shaft.  This  shaft  lends  rigidity  to  the  instrument  suffi- 
cient to  permit  its  accurate  placement,  and  its  small  size  permits 
the  eye  to  keep  the  silk-woven  tip  in  view.  These  endoscopic 
bougies  are  made  in  sizes  from  8  to  40,  French  scale.  The  larger 
sizes  are  used  especially  for  the  dilatation  of  laryngeal  and  tracheal 
stenoses.  For  the  latter  work  it  is  essential  that  the  bougies  be 
inspected  carefully  before  they  are  used,  for  should  a  defective 
tip  come  off  while  in  the  lower  air  passages  a  difficult  foreign  body 
problem  would  be  created.  Soft-rubber  retrograde  dilators  to  be 
drawn  upward  from  the  stomach  by  a  swallowed  string  are  useful 
in  gastrostomized  cases  (Fig.  35). 

Hooks. — No  hook  greater  than  a  right  angle  should  be  used 
through  endoscopic  tubes;  for  should  it  become  caught  in  some 


44 


BRONCHOSCOPY  AND  ESOPHAGOSCOPY 


of  the  smaller  bronchi  its  extraction  might  result  in  serious  trauma. 
The  half  curved  hook  shown  in  Fig.  t,8  is  the  safest  type;  better 
still,  a  spiral  twist  to  the  hook  will  add  to  its  uses,  and  by  reversing 
the  turning  motion  it  may  be  "unscrewed"  out  if  it  becomes 
caught.  Hooks  may  easily  be  made  from  rods  of  malleable  steel 
by  heating  the  end  in  a  spirit  lamp  and  shaping  the  curve  as 

desired  by  means  of  a  pin- vise  and 
pliers.  About  2  cm.  of  the  proximal 
end  of  the  rod  should  be  bent  in 
exactly  the  opposite  direction  from 
that  of  the  hook  so  as  to  form  a 
handle  which  will  tell  the  position 
of  the  hook  by  touch  as  well  as  by 
sight.  Coil-spring  hooks  for  the 
upper-lobe-bronchus  (Fig.  39)  will 
reach  around  the  corner  into  the 
ascending  bronchus  of  the  upper- 
lobe-bronchus,  but  the  utmost  skill 
j^  and  care  are  required  to  make  their 
^'LN^  use  justifiable, 
r:::---,^  C  Safety-pin  Closer. — There  are  a 

Fig  39.— Author's  coil-spring  hook  number  of  methods  for  the   endo- 
for  the  upper-lobe,  bronchus        g^^pj^  removal  of  Open  saf ety-pins 

when  the  point  is  up,  one  of  which  is  by  closing  the  pin  with  the 
instrument  shown  in  Fig.  37  in  the  following  manner.  The  oval 
ring  is  passed  through  the  endoscope  until  it  is  beyond  the  spring 
of  the  safety-pin,  the  ring  is  then  turned  upward  by  depressing 
the  handle,  and  by  the  aid  of  the  prong  the  pin  is  pushed  into 
the  ring,  which  action  approximates  the  point  of  the  pin  and  the 
keeper  and  closes  the  pin.  Removal  is  then  less  difficult  and 
without  danger.  This  instrument  may  also  be  used  as  a  mech- 
anical spoon,  in  which  case  it  may  be  passed  to  the  side  of  a 


IXSTRUMEXTARIUM  45 

difficultly  grasped  foreign  body,  such  as  a  pebble,  the  ring  ele- 
vated and  the  object  withdrawn.  Elsewhere  will  be  found  a 
description  of  the  various  safety-pin  closers  devised  by  various 
endoscopists.  The  author  has  used  Arrowsmith's  closer  with 
much  satisfaction. 

Mechanical  Spoon.- — When  soft,  friable  substances,  such  as  a 
bolus  of  meat,  become  impacted  in  the  upper  esophagus,  the  short 
mechanical  spoon  (Fig.  30)  used  through  the  esophageal  speculum 
is  of  great  aid  in  their  removal.  The  blade  in  this  instrument,  as 
the  name  suggests,  is  a  spoon  and  is  not  fenestrated  as  is  the 
safety-pin  closer,  which  if  used  for  friable  substances  would  allow 
them  to  slip  through  the  fenestration.  A  longer  form  for  use 
through  bronchoscopes  and  esophagoscopes  is  shown  in  Fig.  36. 

A  laryngeal  curette,  cautery  electrodes,  cautery  handle,  and 
laryngeal  knife  are  illustrated  in  Fig.  34.  The  cautery  is  to  be 
used  with  a  transformer,  or  a  storage  battery. 

Spectacles. — If  the  operator  has  no  refractive  error  he  will  need 
two  pairs  of  plane  protective  spectacles  with  very  large  "eyes."  If 
ametropic,  corrective  lenses  are  necessary,  and  duplicate  spectacles 
must  be  in  charge  of  a  nurse.  For  presbyopia  two  pairs  of  spec- 
tacles for  40  cm.  distance  and  65  cm.  distance  must  be  at  hand. 
Hook  temple  frames  should  be  used  so  that  they  can  be  easily 
changed  and  adjusted  by  the  nurse  when  the  lenses  become  spat- 
tered. The  spectacle  nurse  has  ready  at  all  times  the  extra  spec- 
tacles, cleaned  and  warmed  in  a  pan  of  heated  water  so  that  they 
will  not  be  fogged  by  the  patient's  breath,  and  she  changes  them 
without  delay  as  often  as  they  become  soiled.  The  operator 
should  work  with  both  eyes  open  and  with  his  right  eye  at  the 
tube  mouth.  The  operating  room  should  be  somewhat  darkened 
so  as  to  facilitate  the  ignoring  of  the  image  in  the  left  eye;  any 
lighting  should  be  at  the  operator's  back,  and  should  be  insufficient 
to  cause  reflections  from  the  inner  surface  of  his  glasses. 


46 


BRONCHOSCOPY  AND  ESOPHAGOSCOPY 


Endoscopic  Table. — Any  operating  table  may  be  used,  but  the 
work  is  facilitated  if  a  special  table  can  be  had  which  allows  the 


c 


I&crd 


Fig.  40. — The  author's  endoscopic  bougies.  The  end  consists  of  a  flexible  silk 
woven  tip  attached  securely  to  a  steel  shank.  Sizes  8  to  30  French  catheter  scale. 
A  metallic  form  of  this  bougie  is  useful  in  the  trachea;  but  is  not  so  safe  for  esophageal 
use. 


Fig.  41. — The  author's  laryngeal  bougie  for  the  dilatation  of  cicatricial  larj'ngeal 
stenosis.  Made  in  10  sizes.  The  shaded  triangle  shows  the  cross-section  at  the 
widest  part. 


^-Httdpiece   dropped 
,'  ai/fomtrice/ly  j/hen  . 

upper  pfafform  is 

drawn   fotffard  ,  ',>. 


operator 


false  top  < 


Fig.  42 — The  author's  bronchoscopic  and  esophagoscopic  table. 

placing  of  the  patient  in  all  required  positions.  The  table  illus- 
trated in  Fig.  42  is  so  arranged  that  when  the  false  top  is  drawn 
forward  on  the  railroad,  the  head  piece  drops  and  the  patient  is 
placed  in  the  correct  (Boyce)  position  for  esophagoscopy  or  bron- 


INSTRUMENTARIUM 


47 


choscopy,  i.e.,  with  the  head  and  shoulders  extending  over  the  end 
of  the  table.  By  means  of  the  wheel  the  plane  of  the  table  may 
be  altered  to  any  desired  angle  of  inclination  or  height  of  head. 
Operating  Room. — All  endoscopic  procedures  should  be  per- 
formed in  a  somewhat  darkened  operating  room  where  all  the 
desired  materials  are  at  hand.  An  endoscopic  team  consists  of 
three  persons:  the  operator,  the  assistant  who  holds  the  head,  and 
the  instrument  assistant.  Another  person  is  required  to  hold  the 
patient's  arms  and  still  another  for  the  changing  of  the  operator's 
glasses  when  they  become  spattered.     The  endoscopic  team  of 


Fig.  43. — The  author's  retrograde  esophagoscope. 

three  maintain  surgical  asepsis  in  the  matter  of  hands  and  gowns, 
etc.  The  battery,  on  a  small  table  of  its  own,  is  placed  at  the  left 
hand  of  the  operator.  Beyond  it  is  the  table  for  the  mechanical 
aspirator,  if  one  is  used.  All  extra  instruments  are  placed  on  a 
sterile  table,  within  reach,  but  not  in  the  way,  while  those  instru- 
ments for  use  in  the  particular  operation  are  placed  on  a  small 
instrument  table  back  of  the  endoscopist.  Only  those  instruments 
likely  to  be  wanted  should  be  placed  on  the  working  table,  so 
that  there  shall  be  no  confusion  in  their  selection  by  the  instru- 
ment nurse  when  called  for.  Each  moment  of  time  should  be 
utilized  when  the  endoscopic  procedure  has  been  started,  no  time 
should  be  lost  in  the  hunting  or  separating  of  instruments.     To 


48  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

have  the  respective  tables  always  in  the  same  position  relative  to 
the  operator  prevents  confusion  and  avoids  delay. 

Oxygen  Tank  and  Tracheotomy  Instruments. — Respiratory 
arrest  may  occur  from  shifting  of  a  foreign  body,  pressure  of  the 
esophagoscope,  tumor,  or  diverticulum  full  of  food.  Rare  as 
these  contingencies  are,  it  is  essential  that  means  for  resuscitation 
be  at  hand.  No  endoscopic  procedure  should  be  undertaken 
without  a  set  of  tracheotomy  instruments  on  the  sterile  table 
within  instant  reach.  In  respiratory  arrest  from  the  above  men- 
tioned causes,  respiratory  efforts  are  not  apt  to  return  unless  oxy- 
gen and  amyl  nitrite  are  blown  into  the  trachea  either  through  a 
tracheotomy  opening  or  better  still  by  means  of  a  bronchoscope 
introduced  through  the  larynx.  The  limpness  of  the  patient 
renders  bronchoscopy  so  easy  that  the  well-drilled  bronchoscopist 
should  have  no  difficulty  in  inserting  a  bronchoscope  in  lo  or  15 
seconds,  if  proper  preparedness  has  been  observed.  It  is  perhaps 
relatively  rarely  that  such  accidents  occur,  yet  if  preparations 
are  made  for  such  a  contingency,  a  life  may  be  saved  which  would 
otherwise  be  inevitably  lost.  The  oxygen  tank  covered  with  a 
sterile  muslin  cover  should  stand  to  the  left  of  the  operating 
table. 

Asepsis. — Strict  aseptic  technic  must  be  observed  in  all 
endoscopic  procedures.  The  operator,  first  assistant,  and  instru- 
ment nurse  must  use  the  same  precautions  as  to  hand  sterilization 
and  sterile  gowns  as  would  be  exercised  in  any  surgical  operation. 
The  operator  and  first  assistant  should  wear  masks  and  sterile 
gloves.  The  patient  is  instructed  to  cleanse  the  mouth  thoroughly 
with  the  tooth  brush  and  a  20  per  cent  alcohol  mouth  wash. 
Any  dental  defects  should,  if  time  permit,  as  in  a  course  of  re- 
peated treatments,  be  remedied  by  the  dental  surgeon.  When 
placed  on  the  table  with  neck  bare  and  the  shoulders  unhampered 
by  clothing,  the  patient  is  covered  with  a  sterile  sheet  and  the 


INSTRUMENTARIUM  49 

head  is  enfolded  in  a  sterile  towel.  The  face  is  wiped  with  70 
per  cent  alcohol. 

It  is  to  be  remembered  that  while  the  patient  is  relatively 
immune  to  the  bacteria  he  himself  harbors,  the  implantation  of 
different  strains  of  perhaps  the  same  type  of  organisms  may  prove 
virulent  to  him.  Furthermore  the  transference  of  lues,  tubercu- 
losis, diphtheria,  pneumonia,  erysipelas  and  other  infective  dis- 
eases would  be  inevitable  if  sterile  precautions  were  not  taken. 

All  of  the  tubes  and  forceps  are  sterilized  by  boiling.  The 
light-carriers  and  lamps  may  be  sterilized  by  immersion  in  95 
per  cent  alcohol  or  by  prolonged  exposure  to  formaldehyde  gas. 
Continuous  sterilization  by  keeping  them  put  away  in  a  metal 
box  with  formalin  pastilles  or  other  source  of  formaldehyde  gas 
is  an  ideal  method.  Knives  and  scissors  are  immersed  in  95  per 
cent  alcohol,  and  the  rubber  covered  conducting  cords  are  wiped 
with  the  same  solution. 

List  of  Instruments. — The  following  list  has  been  compiled 
as  a  convenient  basis  for  equipment,  to  which  such  special  instru- 
ments as  may  be  needed  for  special  cases  can  be  added  from  time 
to  time.     The  instruments  listed  are  of  the  author's  design. 

I  adult's  laryngoscope. 
I  child's  laryngoscope. 
I  infant's  diagnostic  laryngoscope. 
I  anterior  commissure  laryngoscope. 
I  bronchoscope,  4  mm.  X  30  cm. 
I  bronchoscope,  5  mm.  X  30  cm. 
I  bronchoscope,  7  mm.  X  40  cm. 
I  bronchoscope,  9  mm.  X  40  cm. 
I  esophagoscope,  7  mm.  X  45  cm. 
I  esophagoscope,  10  mm.  X  Si  cm. 
I  esophagoscope,  full  lumen,  7  mm.  X  45  cm. 
I  esophagoscope,  fidl  lumen,  9  mm.  X  45  cm. 
I  esophageal  speculum,  adult. 
I  esophageal  speculum,  child. 
I  forward-grasping  forceps,  delicate,  40  cm. 
4 


50  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

I  forward-grasping  forceps,  regular,  50  cm. 
I  forward-grasping  forceps,  regular,  60  cm. 
I  side-grasping  forceps,  delicate,  40  cm. 
I  side-grasping  forceps,  regular,  50  cm. 
I  side-grasping  forceps,  regular,  60  cm. 
I  rotation  forceps,  delicate,  40  cm. 
I  rotation  forceps,  regular,  50  cm. 
I  rotation  forceps,  regular,  60  cm. 
I  laryngeal  alligator  forceps. 
I  laryngeal  papilloma  forceps. 
ID  esophageal  bougies,  Nos.  8  to  17  French  (larger  sizes  to  No.  36  may  be 
added) . 
I  special  measuring  rule. 
6  light  sponge  carriers. 

1  aspirator  with  double  tube  for  minus  and  plus  pressure. 

2  endoscopic  aspirating  tubes  30  and  50  cm. 
I  half  curved  hook,  60  cm. 

I  triple  circuit  bronchoscopy  battery. 

6  rubber  covered  conducting  cords  for  battery. 

I  box  bronchoscopic  sponges,  size  4. 

I  box  bronchoscopic  sponges,  size  5. 

I  box  bronchoscopic  sponges,  size  7. 

I  box  bronchoscopic  sponges,  size  10. 

I  bite  block,  i  adult. 

1  bite  block,  child. 

2  dozen  extra  lamps  for  lighted  instruments. 
I  extra  light  carrier  for  each  instrument.* 

4  yards  of  pipe-cleaning,  worsted-covered  wire. 

Care  of  Instruments. — The  endoscopist  must  either  personally 
care  for  his  instruments,  or  have  an  instrument  nurse  in  his  own 
employ,  for  if  they  are  intrusted  to  the  general  operating  room 
routine  he  will  find  that  small  parts  will  be  lost;  blades  of  forceps 
bent,  broken,  or  rusted;  tubes  dinged;  drainage  canals  choked  with 
blood  or  secretions  which  have  been  coagulated  by  boiling,  and 
electric  attachments  rendered  unstable  or  unservicable,  by  boiling, 
etc.  The  tubes  should  be  cleansed  by  forcing  cold  water  through 
the  drainage  canals  with  the  aspirating  syringe,  then  dried  by 

*  Messrs.  George  P.  Pilling  and  Sons  who  are  now  making  these  instruments 
supply  an  extra  light  carrier  and  2  extra  lamps  with  each  instrument. 


PLATE  I 

A  Working  Set  of  the  Author's  Endoscopic  Tubes  for  Laryngoscopy,  Bron- 
choscopy, ESOPHAGOSCOPY,  AND  GaSTROSCOPY: 

A,  Adult's  laryngoscope;  B,  child's  laryngoscope;  C,  anterior  commissure  laryngo- 
scope; D,  esophageal  speculum,  child's  size;  E,  esophageal  speculum,  adult's  size; 
F,  bronchoscope,  infant's  size,  4  mm.  x  30  cm.;  G,  bronchoscope,  child's  size,  5  mm.  x 
30  cm.;  H,  aspirating  bronchoscope  for  adults,  7  mm.  x  40  cm.;  I,  bronchoscope,  ado- 
lescent's size,  7  mm.  x  40  cm.,  used  also  for  the  deeper  bronchi  of  adults;  J,  broncho- 
scope, adult  size,  9  mm.  x  40  cm.;  K,  child's  size  esophagoscop>e,  7  mm.  x  45  cm.;  L, 
adult's  size  esophagoscope,  full  lumen  construction,  9  mm.  x  45  cm.;  M,  adult's  size 
gastroscope.  C,  D,  and  E  are  also  hypopharyngoscopes.  C  is  an  excellent  esopha- 
geal speculum  for  children,  and  a  longer  model  is  made  for  adults. 

If  the  utmost  economy  must  be  practised  D,  E,  and  M  may  be  omitted.  The 
balance  of  the  Instruments  are  indispensable  if  adults  and  children  are  to  be  dealt  with. 

The  instruments  are  made  by  Charles  J.  Pilling  &  Sons,  Philadelphia. 


PLATE   I 


&.  M 


INSTRUMENTARIUM  5 1 

forcing  pipe-cleaning  worsted-covered  wire  through  the  Kght  and 
drainage  canals.  Gauze  on  a  sponge  carrier  is  used  to  clean  the 
main  canal.  Forceps  stylets  should  be  removed  from  their  can- 
nulae,  and  the  cannulae  cleansed  with  cold  water,  then  dried  and 
oiled  with  the  pipe-cleaning  material.  The  stylet  should  have 
any  rough  places  smoothed  with  fine  emery  cloth  and  its  blades 
carefully  inspected;  the  parts  are  then  oiled  and  reassembled. 
Nickle  plating  on  the  tubes  is  apt  to  peel  and  these  scales  have 
sharp,  cutting  edges  which  may  injure  the  mucosa.  All  tubes, 
therefore,  should  be  unplated.  Rough  places  on  the  tubes  should 
be  smoothed  with  the  finest  emery  cloth,  or,  better,  on  a  buffing 
wheel.  The  dry  cells  in  the  battery  should  be  renewed  about 
every  4  months  whether  used  or  not.  Lamps,  light  carriers,  and 
cords,  after  cleansing,  are  wiped  with  95  per  cent  alcohol,  and  the 
light-carriers  with  the  lamps  in  place  are  kept  in  a  continuous 
steriHzation  box  containing  formaldehyde  pastilles.  It  is  of  the 
utmost  importance  that  instruments  be  always  put  away  in  per- 
fect order.  Not  only  are  cleaning  and  oiling  imperative,  but  any 
needed  repairs  should  be  attended  to  at  once.  Otherwise  it  will 
be  inevitable  that  when  gotten  out  in  an  emergency  they  will  faiL 
In  general  surgery,  a  spoon  will  serve  for  a  retractor  and  good  work 
can  be  done  with  makeshifts;  but  in  endoscopy,  especially  in  the 
small,  deUcate,  natural  passages  of  children,  the  handicap  of  a 
defective  or  insufficient  armamentarium  may  make  all  the  differ- 
ence between  a  success  and  a  fatal  failure. 

A  bronchoscopic  clinic  should  at  all  times  be  in  the  same  state 
of  preparedness  for  emergency  as  is  everywhere  required  of  a 
fire-engine  house. 


CHAPTER  II 

ANATOMY  OF  LARYNX,  TRACHEA,  BRONCHI  AND 
ESOPHAGUS,  ENDOSCOPIC  ALLY  CONSIDERED 

The  larynx  is  a  cartilaginous  box,  triangular  in  cross-section, 
with  the  apex  of  the  triangle  directed  anteriorly.  It  is  readily 
felt  in  the  neck  and  is  a  landmark  for  the  operation  of  tracheotomy. 
We  are  concerned  endoscopically  with  four  of  its  cartilaginous 
structures:  the  epiglottis,  the  two  arytenoid  cartilages,  and  the 
cricoid  cartilage.  The  epiglottis,  the  first  landmark  in  direct 
laryngoscopy,  is  a  leaf-Hke  projection  springing  from  the  anteroin- 
ternal  surface  of  the  larynx  and  having  for  its  function  the  direct- 
ing of  the  bolus  of  food  into  the  pyriform  sinuses.  It  does  not 
close  the  larynx  in  the  trap-door  manner  formerly  taught;  a  fact 
easily  demonstrated  by  the  simple  insertion  of  the  direct  laryngo- 
scope and  further  demonstrated  by  the  absence  of  dysphagia  when 
the  epiglottis  is  surgically  removed,  or  is  destroyed  by  ulceration. 
Closure  of  the  larynx  is  accomplished  by  the  approximation 
of  the  ventricular  bands,  arytenoids  and  ary epiglottic  folds,  the 
latter  having  a  sphincter-like  action,  and  by  the  raising  and  tilting 
of  the  larynx.  The  arytenoids  form  the  upper  posterior  boundary 
of  the  larynx  and  our  particular  interest  in  them  is  directed  toward 
their  motility,  for  the  rotation  of  the  arytenoids  at  the  crico- 
arytenoid articulations  determines  the  movements  of  the  cords 
and  the  production  of  voice.  Approximation  of  the  arytenoids 
is  a  part  of  the  mechanism  of  closure  of  the  larynx. 

The  cricoid  cartilage  was  regarded  by  esophagoscopists  as  the 

chief  obstruction  encountered  on  the  introduction  of  the  esophago- 

scope.     As  shown  by  the  author,  it  is  the  cricopharyngeal  fold, 

52 


J  JO  .0 


ANATOMY  OF  LARYNX,  TRACHEA,  BRONCHI  AND  ESOPHAGUS         53 

and  the  inconceivably  powerful  pull  of  the  cricopharyngeal 
muscle  on  the  cricoid  cartilage,  that  causes  the  difficulty.  The 
cricoid  is  pulled  so  powerfully  back  against  the  cervical  spine, 
that  it  is  hard  to  believe  that  this  muscles  is  inserted  into  the 
median  raphe  and  not  into  the  spine  itself  (Fig.  68). 

The  ventricular  bands  or  false  vocal  cords  vicariously  phonate 
in  the  absence  of  the  true  cords,  and  assist  in  the  protective 
function  of  the  larynx.  They  form  the  floor  of  the  ventricles  of 
the  larynx,  which  are  recesses  on  either  side,  between  the  false  and 
true  cords,  and  contain  numerous  mucous  glands  the  secretion 
from  which  lubricates  the  cords.  The  ventricles  are  not  visible 
by  mirror  laryngoscopy,  but  are  readily  exposed  in  their  depths 
by  lifting  the  respective  ventricular  bands  with  the  tip  of  the 
laryngoscope.  The  vocal  cords,  which  appear  white,  fiat,  and 
ribbon-like  in  the  mirror,  when  viewed  directly  assume  a  reddish 
color,  and  reveal  their  true  shelf-like  formation.  In  the  subglottic 
area  the  tissues  are  vascular,  and,  in  children  especially,  they  are 
prone  to  swell  when  traumatized,  a  fact  which  should  be  always 
in  mind  to  emphasize  the  importance  of  gentleness  in  bronchos- 
copy, and  furthermore,  the  necessity  of  avoiding  this  region  in 
tracheotomy  because  of  the  danger  of  producing  chronic  laryngeal 
stenosis  by  the  reaction  of  these  tissues  to  the  presence  of  the 
tracheotomic  cannula. 

The  trachea  just  below  its  entrance  into  the  thorax  deviates 
sUghtly  to  the  right,  to  allow  room  for  the  aorta.  At  the  level  of 
the  second  costal  cartilage,  the  third  in  children,  it  bifurcates  into 
the  right  and  left  main  bronchi.  Posteriorly  the  bifurcation 
corresponds  to  about  the  fourth  or  fifth  thoracic  vertebra,  the 
trachea  being  elastic,  and  displaced  by  various  movements.  The 
endoscopic  appearance  of  the  trachea  is  that  of  a  tube  flattened 
on  its  posterior  wall.  In  two  locations  it  normally  often  assumes 
a  more  or  less  oval  outhne;  in  the  cervical  region,  due  to  pressure 


54 


BROXCHOSCOPY  AND  ESOPHAGOSCOPY 


of  the  thyroid  gland;  and  in  the  intrathoracic  portion  just  above 
the  bifurcation  where  it  is  crossed  by  the  aorta.  This  latter 
flattening  is  rhythmically  increased  with  each  pulsation.  Under 
pathological  conditions,  the  tracheal  outline  may  be  variously 
altered,  even  to  obHteration  of  the  lumen.  The  mucosa  of  the 
trachea  and  bronchi  is  moist  and  ghstening,  whitish  in  circular 

ridges  corresponding  to  the  cartila- 
ginous rings,  and  reddish  in  the 
intervening  grooves. 

The  right  main  bronchus  is 
shorter,  wider,  and  more  nearly 
vertical  than  its  fellow  of  the  oppo- 
site side,  and  is  practically  the  con- 
tinuation of  the  trachea,  while  the 
left  bronchus  might  be  considered 
as  a  branch.  The  deviation  of  the 
right  main  bronchus  is  about  25°, 
and  its  length  unbranched  in  the 
adult  is  about  2.5  cm.  The  devia- 
tion of  the  left  main  bronchus  is 
about  75°  and  its  adult  length  is 
about  5  cm.  The  right  bronchus 
considered  as  a  stem,  may  be  said  to 
give  off  three  branches,  the  epi- 
arterial,  upper-  or  superior-lobe  bronchus;  the  middle-lobe  bron- 
chus; and  the  continuation  downward,  called  the  lower-  or 
inferior-lobe  bronchus,  which  gives  off  dorsal,  ventral  and  lateral 
branches.  The  left  main  bronchus  gives  off  first  the  upper- 
or  superior-lobe  bronchus,  the  continuation  being  the  lower- 
or  inferior-lobe  bronchus,  consisting  of  a  stem  with  dorsal,  ventral 
and  lateral  branches. 

The  septum  between  the  right  and  left  main  bronchi,  termed 


Fig.  44. — Tracheo-bronc  h  i  a  1 
tree.  LM,  Left  main  bronchus; 
SL,  superior  lobe  bronchus;  IVIL, 
middle  lobe  bronchus;  IL.  inferior 
lobe  bronchus. 


ANATOMY  OF  LARYNX,  TRACHEA,  BRONCHI  AND  ESOPHAGUS 


:>:> 


the  carina,  is  situated  to  the  left  of  the  midtracheal  Hne.  It  is 
recognized  endoscopically  as  a  short,  shining  ridge  running  sagi- 
tally,  or,  as  the  patient  Hes  in  the  recumbent  position,  we  speak  of 
it  as  being  vertical.  On  either  side  are  seen  the  openings  of  the 
right  and  left  main  bronchi.  In  Fig.  44,  it  will  be  seen  that  the 
lower  border  of  the  carina  is  on  a  level  with  the  upper  portion  of 
the  orifice  of  the  right  superior-lobe  bronchus;  with  the  carina  as  a 
landmark  and  by  displacing  with  the  bronchoscope  the  lateral 


Left  bronchus.  Right  bronchus. 

Fig.  45. — Bronchoscopic  views. 
S,  Superior  lobe  bronchus;  SL.  superior  lobe  bronchus;  I,  inferior  lobe  bronchus; 
M,  middle  lobe  bronchus. 


wall  of  the  right  main  bronchus,  a  second,  smaller,  vertical  spur 
appears,  and  a  view  of  the  orifice  of  the  right  upper-lobe  bronchus 
is  obtained,  though  a  lumen  image  cannot  be  presented.  On 
passing  down  the  right  stem  bronchus  (patient  recumbent)  a 
horizontal  partition  or  spur  is  found  with  the  lumen  of  the  middle- 
lobe  bronchus  extending  toward  the  ventral  surface  of  the  body. 
All  below  this  opening  of  the  right  middle-lobe  bronchus  consti- 
tutes the  lower-lobe  bronchus  and  its  branches. 


56 


BRONCHOSCOPY  AND  ESOPHAGOSCOPY 


Coming  back  to  the  carina  and  passing  down  the  left  bronchus^ 
the  relatively  great  distance  from  the  carina  to  the  upper-lobe 
bronchus  is  noted.  The  spur  dividing  the  orifices  of  the  left 
upper-  and  lower-lobe  bronchi  is  oblique  in  direction,  and  it  is 
possible  to  see  more  of  the  lumen  of  the  left  upper-lobe  bronchus 
than  of  its  homologue  on  the  right.  Below  this  are  seen  the  lower- 
lobe  bronchus  and  its  divisions  (Fig.  45). 

Dimensions  of  the  Trachea  and  Bronchi. — It  will  be  noted  that 
the  bronchi  divide  monopodially,  not  dichotomously.  While  the 
lumina  of  the  individual  bronchi  diminish  as  the  bronchi  divide, 
the  sum  of  the  areas  shows  a  progressive  increase  in  total  tubular 
area  of  cross-section.  Thus,  the  sum  of  the  areas  of  cross-section 
of  the  two  main  bronchi,  right  and  left,  is  greater  than  the  area 
of  cross  section  of  the  trachea.  This  follows  the  well  known  dyna- 
mic law.  The  relative  increase  in  surface  as  the  tubes  branch  and 
diminish  in  size  increases  the  friction  of  the  passing  air,  so  that  an 
actual  increase  in  area  of  cross  section  is  necessary,  to  avoid 
increasing  resistance  to  the  passage  of  air. 

The  cadaveric  dimensions  of  the  tracheobronchial  tree  may  be 
epitomized  approximately  as  follows: 


Adult 
male 

Female 

Child 

14  X  20 

12  X  16 

8  X  10 

12.0 

10. 0 

6.0 

^•S 

2-5 

2.0 

50 

S-o 

30 

15.0 

13.0 

10. 0 

32.0 

28.0 

19.0 

Infant 


Diameter  trachea, 

Length  trachea,  cm 

Length  right  bronchus 

Length  left  bronchus 

Length  upper  teeth  to  trachea 

Length  total  to  secondary  bronchus 


6X7 
4.0 

i-S 

2-5 

9.0 

150 


In  considering  the  foregoing  table  it  is  to  be  remembered  that 
in  life  muscle  tonus  varies  the  lumen  and  on  the  whole  renders  it 
smaller.     In  the  selection  of  tubes  it  must  be  remembered  that 


ANATOMY  OF  LARYNX,  TRACHEA,  BRONCHI  AND  ESOPHAGUS         57 

the  full  diameter  of  the  trachea  is  not  available  on  account  of  the 
glottic  aperture  which  in  the  adult  is  a  triangle  measuring  approxi- 
mately 12X22X22  mm.  and  permitting  the  passage  of  a  tube 
not  over  lo  mm.  in  diameter  without  risk  of  injury.  Furthermore 
a  tube  which  filled  the  trachea  would  be  too  large  to  enter  either 
main  bronchus. 

The  normal  movements  of  the  trachea  and  bronchi  are  respiratory, 
pulsatory,  bechic,  and  deglutitory.  The  two  former  are  rhythmic 
while  the  two  latter  are  intermittently  noted  during  bronchoscopy. 
It  is  readily  observed  that  the  bronchi  elongate  and  expand 
during  inspiration  while  during  expiration  they  shorten  and 
contract.  The  bronchoscopist  must  learn  to  work  in  spite  of  the 
fact  that  the  bronchi  dilate,  contract,  elongate,  shorten,  kink,  and 
are  dinged  and  pushed  this  way  and  that.  It  is  this  resiliency  and 
movability  that  make  bronchoscopy  possible.  The  inspiratory 
enlargement  of  lumen  opens  up  the  forceps  spaces,  and  the  facile 
bronchoscopist  avails  himself  of  the  opportunity  to  seize  the 
foreign  body. 

THE  ESOPHAGUS 

A  few  of  the  anatomical  details  must  be  kept  especially  in 
mind  when  it  is  desired  to  introduce  straight  and  rigid  instruments 
down  the  lumen  of  the  gullet.  First  and  most  important  is  the 
fact  that  the  esophageal  walls  are  exceedingly  thin  and  delicate 
and  require  the  most  careful  manipulation.  Because  of  this 
delicacy  of  the  walls  and  because  the  esophagus,  being  a  constant 
passageway  for  bacteria  from  the  mouth  to  the  stomach,  is  never 
sterile,  surgical  procedures  are  associated  with  infective  risks. 
For  some  other  and  not  fully  understood  reason,  the  esophagus  is, 
surgically  speaking,  one  of  the  most  intolerant  of  all  human 
viscera.  The  anterior  wall  of  the  esophagus  is  in  a  part  of  its 
course,  in  close  relation  to  the  posterior  wall  of  the  trachea,  and 


BRONCHOSCOPY  AND  ESOPHAGOSCOPY 


BIR-ffl 

lyr. 

3yrs. 

6yrs. 

iOyrs. 

I4yrs. 

ADULTS 

23 

27 

30 

33 

36 

43 

53  Cm. 

GREATER   CURVATURE! 

18 

20 

22 

25 

27 

34 

40  Cm. 

/    / 

CARDIA           X.^                 \ 

/ 

19 

21 

23 

24 

25 

31 

36  Cm. 

HIATUS                            1       I 

13 

15 

16 

18 

20 

24 

27  Cm 

y 

LEFT  BRONCHUS     ^  ^  KV  ^ 

12 

14 

15 

16 

17 

21 

23Cm. 

y 

AORTA                    -_/ 

7 

9 

10 

II 

12 

14 

16  Cm. 

r 

CRICOPHARYINGEUS     1         ( 

ESOPHAGOSCOPIC 

AND 

GASTROSCOPIC 
CHART 

INCISORS 

^ 

\ 

Fig.  46. — The  author's  esophagoscopic  chart  of  approximate  distances  of  the 
esophageal  narrowings  from  the  upper  incisor  teeth,  arranged  for  convenient  refer- 
ence during  esophagoscopy  in  the  dorsally  recumbent  patient. 


ANATOMY  OF  LARYNX,  TRACHEA,  BRONCHI  AND  ESOPHAGUS    59 

this  portion  is  called  the  party  wall.  It  is  this  party  wall  that 
contains  the  lymph  drainage  system  of  the  posterior  portion  of  the 
larynx,  and  it  is  largely  by  this  route  that  posteriorly  located 
malignant  laryngeal  neoplasms  early  metastasize  to  the 
mediastinum. 

The  lengths  of  the  esophagus  at  different  ages  are  shown  dia- 
grammatically  in  Fig.  46.  The  diameter  of  the  esophageal  lumen 
varies  greatly  with  the  elasticity  of  the  esophageal  walls;  its  diam- 
eter at  the  four  points  of  anatomical  constriction  is  shown  in  the 
following  table: 


Constriction 


Diameter 


Vertebra 


Cricopharyngeal 

Transverse  23  mm.  (i  in.) 
Antero-posterior  17  mm.  (%  in.) 

Sixth  cervical 

Aortic 

Transverse  24  mm.  (i  in.) 
Antero-posterior  19  mm.  (%  in.) 

Fourth  thoracic 

Left-bronchial 

Transverse  23  mm.  (i  in.) 
Antero-posterior  17  mm.  (%  in.) 

Fifth  thoracic 

Diaphragmatic 

Transverse  23  mm.  (i  in-|-) 
Antero-posterior  23  mm.  (in.  —  ) 

Tenth  thoracic 

For  practical  endoscopic  purposes  it  is  only  necessary  to  remember 
that  in  a  normal  esophagus,  straight  and  rigid  tubes  of  7  mm.  diam- 
eter should  pass  freely  in  infants,  and  in  adults,  tubes  of  10  mm. 
The  4  demonstrable  constrictions  from  above  downward  are  at 

1.  The  crico-pharyngeal  fold. 

2.  The  crossing  of  the  aorta. 

3.  The  crossing  of  the  left  bronchus. 

4.  The  hiatus  esophageus. 

There  is  a  definite  fifth  narrowing  of  the  esophageal  lumen 
not  easily  demonstrated  esophagoscopically  and  not  seen  during 
dissection,  but  readily  shown  functionally  by  the  fact  that  almost 
all  foreign  bodies  lodge  at  this  point.     This  narrowing  occurs  at 


6o  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

the  superior  aperture  of  the  thorax  and  is  probably  produced  by 
the  crowding  of  the  numerous  organs  which  enter  or  leave  the 
thorax  through  this  orifice. 

The  crico- pharyngeal  constriction,  as  already  mentioned,  is 
produced  by  the  tonic  contraction  of  a  specialized  band  of  the 
orbicular  fibers  of  the  lowermost  portion  of  the  inferior  pharyngeal 
constrictor  muscle,  called  the  cricopharyngeal  muscle.  As 
shown  by  the  author  it  is  this  muscle  and  not  the  cricoid  cartilage 
alone  that  causes  the  difficulty  in  the  insertion  of  an  esophagoscope. 

This  muscle  is  attached  laterally  to  the  edges  of  the  signet  of 
the  cricoid  which  it  pulls  with  an  incomprehensible  power  against 
the  posterior  wall  of  the  hypopharynx,  thus  closing  the  mouth  of 
the  esophagus.  Its  other  attachment  is  in  the  median  posterior 
raphe.  Between  these  circular  fibers  (the  cricopharyngeal  muscle) 
and  the  oblique  fibers  of  the  inferior  constrictor  muscle  there  is  a 
weakly  supported  point  through  which  the  esophageal  wall  may 
herniate  to  form  the  so-called  pulsion  diverticulum.  It  is  at 
this  weak  point  that  fatal  esophagoscopic  perforation  by  inexperi- 
enced operators  is  most  likely  to  occur. 

The  aortic  narrowing  of  the  esophagus  may  not  be  noticed  at 
all  if  the  patient  is  placed  in  the  proper  sequential  "high-low" 
position.  It  is  only  when  the  tube-mouth  is  directed  against  the 
left  anterior  wall  that  the  actively  pulsating  aorta  is  felt. 

The  bronchial  narrowing  of  the  esophagus  is  due  to  backward 
displacement  caused  by  the  passage  of  the  left  bronchus  over  the 
anterior  wall  of  the  esophagus  at  about  27  cm.  from  the  upper 
teeth  in  the  adult.  The  ridge  is  quite  prominent  in  some  patients, 
especially  those  with  dilatation  from  stenoses  lower  down. 

The  hiatal  narrowing  is  both  anatomic  and  spasmodic.  The 
peculiar  arrangement  of  the  tendinous  and  muscular  structure  of 
the  diaphragm  acts  on  this  hiatal  opening  in  a  sphincter-like 
fashion.     There  are  also  special  bundles  of  muscle  fibers  extending 


ANATOMY  OF  LARYNX,  TRACHEA,  BRONCHI  AND  ESOPHAGUS    6 1 

from  the  crura  of  the  diaphragm  and  surrounding  the  esophagus, 
which  contribute  to  tonic  closure  in  the  same  way  that  a  pinch- 
cock  closes  a  rubber  tube.  The  author  has  called  the  hiatal 
closure  the  "diaphragmatic  pinchcock." 

Direction  of  the  Esophagus. — The  esophagus  enters  the  chest 
in  a  decidedly  backward  as  well  as  downward  direction,  parallel 
to  that  of  the  trachea,  following  the  curves  of  the  cervical  and 
upper  dorsal  spine.  Below  the  left  bronchus  the  esophagus  turns 
forward,  passing  through  the  hiatus  in  the  diaphragm  anterior  to 
and  to  the  left  of  the  aorta.  The  lower  third  of  the  esophagus  in 
addition  to  its  anterior  curvature  turns  strongly  to  the  left,  so 
that  an  esophagoscope  inserted  from  the  right  angle  of  the  mouth, 
when  introduced  into  the  stomach,  points  in  the  direction  of  the 
-anterior  superior  spine  of  the  left  ileum. 

It  is  necessary  to  keep  this  general  course  constantly  in  mind 
in  all  cases  of  esophagoscopy,  but  particularly  in  those  cases  in 
which  there  is  marked  dilatation  of  the  esophagus  following  spasm 
at  the  diaphragm  level.  In  such  cases  the  aid  of  this  knowledge 
of  direction  will  greatly  simplify  the  finding  of  the  hiatus  esopha- 
geus  in  the  floor  of  the  dilatation. 

The  extrinsic  or  transmitted  movements  of  the  esophagus  are 
respiratory  and  pulsatory,  and  to  a  slight  extent,  bechic.  The 
respiratory  movements  consist  in  a  dilatation  or  opening  up  of  the 
thoracic  esophageal  lumen  during  inspiration,  due  to  the  negative 
intrathoracic  pressure.  The  normal  pulsatory  movements  are 
■due  to  the  pulsatile  pressure  of  the  aorta,  found  at  the  4th  thoracic 
vertebra  (24  cm.  from  the  upper  teeth  in  the  adult),  and  of  the 
heart  itself,  most  markedly  felt  at  the  level  of  the  7th  and  8th 
thoracic  vertebrae  (about  30  cm.  from  the  upper  teeth  in  adults). 
As  the  distances  of  all  the  narrowings  vary  with  age,  it  is  useful 
to  frame  and  hang  up  for  reference  a  copy  of  the  chart  (Fig.  46). 

The  intrinsic  movements  of  the  esophagus  are  involuntary 


62  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

muscular  contractions,  as  in  deglutition  and  regurgitation;  spas- 
modic, the  latter  usually  having  some  pathologic  cause;  and  tonic,. 
as  the  normal  hiatal  closure,  in  the  author's  opinion  may  be  con- 
sidered. Swallowing  may  be  involuntary  or  voluntary.  The 
constrictors  are  anatomically  not  considered  part  of  esophagus 
proper.  When  the  constrictors  voluntarily  deliver  the  bolus 
past  the  cricopharyngeal  fold,  the  involuntary  or  peristaltic 
contractions  of  the  esophageal  mural  musculature  carry  the  bolus 
on  downward.  There  is  no  sphincter  at  the  cardiac  end  of  the 
esophagus.  The  site  of  spasmodic  stenosis  in  the  lower  third,  the 
so-called  cardiospasm,  was  first  demonstrated  by  the  author  to  be 
located  at  the  hiatus  esophageus  and  the  spasmodic  contractions 
are  of  the  specialized  muscle  fibers  there  encircling  the  esophagus, 
and  might  be  termed  "phrenospasm,"  or  "hiatal  esophagismus."" 
Regurgitation  of  food  from  the  stomach  is  normally  prevented 
by  the  hiatal  muscular  diaphragmatic  closure  (called  by  the 
author  the  "diaphragmatic  pinchcock")  plus  the  kinking  of  the 
abdominal  esophagus. 

In  the  author's  opinion  there  is  no  spasm  in  the  disease  called 
"cardiospasm."  It  is  simply  the  failure  of  the  diaphragmatic 
pinchcock  to  open  normally  in  the  deglutitory  cycle.  A  better 
name  is  functional  hiatal  stenosis. 

At  retrograde  esophagoscopy  the  cardia  and  abdominal  esopha- 
gus do  not  seem  to  exist.  The  top  of  the  stomach  seems  to  be 
closed  by  the  diaphragmatic  pinchcock  in  the  same  way  that  the 
top  of  a  bag  is  closed  by  a  puckering  string. 


CHAPTER  III 

PREPARATION  OF  THE  PATIENT  FOR  PERORAL 
ENDOSCOPY 

The  suggestions  of  the  author  in  the  earher  volumes  in  regard 
to  preparation  of  the  patient,  as  for  any  operation,  by  a  bath, 
laxative,  etc.,  and  especially  by  special  cleansing  of  the  mouth  with 
25  per  cent  alcohol,  have  received  general  endorsement.  Care 
should  be  taken  not  to  set  up  undue  reaction  by  vigorous  scrubbing 
of  gums  unaccustomed  to  it.  Artificial  dentures  should  be 
removed.  Even  if  no  anesthetic  is  to  be  used,  the  patient  should 
be  fasted  for  five  hours  if  possible,  even  for  direct  laryngoscopy  in 
order  to  forestall  vomiting.  Except  in  emergency  cases  every 
patient  should  be  gone  over  by  an  internist  for  organic  disease 
in  any  form.  If  an  endolaryngeal  operation  is  needed  by  a 
nephritic,  preparatory  treatment  may  prevent  laryngeal  edema  or 
other  complications.  Hemophilia  should  be  thought  of.  It  is  quite 
common  for  the  first  symptom  of  an  aortic  aneurysm  to  be  an 
impaired  power  to  swallow,  or  the  lodgment  of  a  bolus  of  meat  or 
other  foreign  body.  If  aneurysm  is  present  and  esophagoscopy 
is  necessary,  as  it  always  is  in  foreign  body  cases,  "to  be  fore- 
warned is  to  be  forearmed."  Pulmonary  tuberculosis  is  often 
unsuspected  in  very  young  children.  There  is  great  danger 
from  tracheal  pressure  by  an  esophageal  diverticulum  or  dilatation 
distended  with  food;  or  the  food  may  be  regurgitated  and  aspirated 
into  the  larynx  and  trachea.  Therefore,  in  all  esophageal  cases 
the  esophagus  should  be  emptied  by  regurgitation  induced  by 
titillating  the  fauces  with  the  finger  after  swallowing  a  tumberful 
of  water,  pressure  on  the  neck,  etc.  Aspiration  will  succeed  in 
some  cases.     In  others  it  is  absolutely  necessary  to  remove  the 

63 


64  BROXCHOSCOPY  AND  ESOPHAGOSCOPY 

food  with  the  esophagoscope.  If  the  aspirating  tube  becomes 
clogged  by  solid  food,  the  method  of  swab  aspiration  mentioned 
under  bronchoscopy  will  succeed.  Of  course  there  is  usually 
no  cough  to  aid,  but  the  involuntary  abdominal  and  thoracic 
compression  helps.  Should  a  patient  arrive  in  a  serious  state  of 
water-hunger,  as  part  of  the  preparation  the  patient  must  be 
given  water  by  hypodermoclysis  and  enteroclysis,  and  if  necessary 
the  endoscopy,  except  in  dyspneic  cases,  must  be  delayed  until 
the  danger  of  water-starvation  is  past. 

As  pointed  out  by  Ellen  J.  Patterson  the  size  of  the  thymus 
gland  should  be  studied  before  an  esophagoscopy  is  done  on  a 
child. 

Every  patient  should  be  examined  by  indirect,  mirror  laryn- 
goscopy as  a  preliminary  to  peroral  endoscopy  for  any  purpose 
whatsoever.  This  becomes  doubly  necessary  in  cases  that  are  to 
be  anesthetized. 


CHAPTER  IV 
ANESTHESIA  FOR  PERORAL  ENDOSCOPY 

A  dyspneic  patient  should  never  be  given  a  general  anesthetic. 
Cocaine  should  not  be  used  on  children  under  ten  years  of  age 
because  of  its  extreme  toxicity.  To  these  two  postulates  always 
in  mind,  a  third  one,  applicable  to  both  general  and  local  anesthe- 
sia, is  to  be  added — total  abolition  of  the  cough-reflex  should  be  for 
short  periods  only.  General  anesthesia  is  never  used  in  the  Bron- 
choscopic  Clinic  for  endoscopic  procedures.  The  choice  for  each 
operator  must,  however,  be  a  matter  for  individual  decision, 
and  will  depend  upon  the  personal  equation,  and  degree  of  skill 
of  the  operator,  and  his  ability  to  quiet  the  apprehensions  of  the 
patient.  In  other  words,  the  operator  must  decide  what  is  best  for 
his  particular  patient  under  the  conditions  then  existing. 

Children  in  the  Bronchoscopic  Clinic  receive  neither  local  nor 
general  anesthesia,  nor  sedative,  for  laryngoscopic  operations  or 
esophagoscopy.  Bronchoscopy  in  the  older  children  when  no 
dyspnea  is  present  has  in  recent  years,  at  the  suggestion  of  Prof. 
Hare,  been  preceded  by  a  full  dose  of  morphin  sulphate  {i.e.,  }i 
grain  for  a  child  of  six  years)  or  a  full  physiologic  dose  of  sodium 
bromide.  The  apprehension  is  thus  somewhat  allayed  and  the 
excessive  cough-reflex  quieted.  The  morphine  should  be  given 
not  less  than  an  hour  and  a  half  before  bronchoscopy  to  allow 
time  for  the  onset  of  the  soporific  and  antispasmodic  effects 
which  are  the  desiderata,  not  the  analgesic  effects.  Dosage  is 
more  dependent  on  temperament  than  on  age  or  body  weight. 
Atropine  is  advantageously  added  to  morphine  in  bronchoscopy 
for  foreign  bodies,  not  only  for  the  usual  reasons  but  for  its  effect 
as  an  antispasmodic,  and  especially  for  its  diminution  of  endo- 

5  65 


66  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

bronchial  secretions.  True,  it  does  not  diminish  pus,  but  by 
diminishing  the  outpouring  of  normal  secretions  that  dilute  the 
pus  the  total  quantity  of  fluid  encountered  is  less  than  it  otherwise 
would  be.  In  cases  of  large  quantities  of  pus,  as  in  pulmonary 
abscess  and  bronchiectasis,  however,  no  diminution  is  noticeable. 
No  food  or  water  is  allowed  for  5  hours  prior  to  any  endoscopic 
procedure,  whether  sedatives  or  anesthetics  are  to  be  given  or  not. 
If  the  stomach  is  not  empty  vomiting  from  contact  of  the  tube  in 
the  pharynx  will  interfere  with  work. 

With  adults  no  anesthesia,  general  or  local,  is  given  for  esopha- 
goscopy.  For  laryngeal  operation  and  bronchoscopy  the  follow- 
ing technic  is  used: 

One  hour  before  operation  the  patient  is  given  hypodermatic- 
ally  a  full  physiologic  dose  of  morphin  sulphate  (from  }i  to  %  gr.) 
guarded  with  atropin  sulphate  (gr.  3^1^50) •  Care  must  be  taken 
that  the  injection  be  not  given  into  a  vein.  On  the  operating 
table  the  epiglottis  and  pharynx  are  painted  with  10  per  cent 
solution  of  cocain.  Two  applications  are  usually  sufficient  com- 
pletely to  anesthetize  the  exterior  and  interior  of  the  larynx  by 
blocking  of  the  superior  laryngeal  nerve  without  any  endolaryn- 
geal  applications.  The  laryngoscope  is  now  introduced  and  if 
found  necessary  a  20  per  cent  cocain  solution  is  applied  to  the 
interior  of  the  larynx  and  subglottic  region,  by  means  of  gauze 
swabs  fastened  to  the  sponge  carriers.  Here  also  two  applications 
are  quite  sufficient  to  produce  complete  anesthesia  in  the  larynx. 
If  bronchoscopy  is  to  be  done  the  gauze  swab  is  carried  down 
through  the  exposed  glottis  to  the  carina,  thus  anesthetizing  the 
tracheal  mucosa.  If  further  anesthetization  of  the  bronchial 
mucosa  is  required,  cocain  may  be  applied  in  the  same  manner 
through  the  bronchoscope.  In  all  these  local  applications  pro- 
longed contact  of  the  swab  is  much  more  efficient  than  simply 
painting  the  surface. 


ANESTHESIA  FOR  PERORAL  ENDOSCOPY  67 

In  cases  in  which  cocain  is  deemed  contraindicated  morphin 
alone  is  used.  If  given  in  sufficient  dosage  cocain  can  be  alto- 
gether dispensed  with  in  any  case. 

It  is  perhaps  safer  for  the  beginner  in  his  early  cases  of  esopha- 
goscopy  to  have  the  patient  relaxed  by  an  ether  anesthesia, 
provided  the  patient  is  not  dyspneic  to  begin  with,  or  made  so  by 
faulty  position  or  by  pressure  of  the  esophagoscopic  tube  mouth 
on  the  tracheoesophageal  "party  wall."  As  proficiency  develops, 
however,  he  will  find  anesthesia  unnecessary.  Local  anesthesia 
is  needless  for  esophagoscopy,  and  if  used  at  all  should  be  limited 
to  the  laryngopharynx  and  never  applied  to  the  esophagus,  for 
the  esophagus  is  without  sensation,  as  anyone  may  observe  in 
drinking  hot  liquids. 

Direct  laryngoscopy  in  children  requires  neither  local  nor 
general  anesthesia,  either  for  diagnosis  or  for  removal  of  foreign 
bodies  or  growths  from  the  larynx.  General  anesthesia  is  contra- 
indicated  because  of  the  dyspnea  apt  to  be  present,  and  because 
the  struggles  of  the  patient  might  cause  a  dislodgment  of  the 
laryngeal  intruder  and  aspiration  to  a  lower  level.  The  lat- 
ter accident  is  also  prone  to  follow  attempts  to  cocainize  the 
larynx. 

Technic  for  General  Anesthesia. — For  esophagoscopy  and  gas- 
troscopy,  if  general  anesthesia  is  desired,  ether  may  be  started  by 
the  usual  method  and  continued  by  dropping  upon  folded  gauze 
laid  over  the  mouth  after  the  tube  is  introduced.  Endo-tracheal 
administration  of  ether  is,  however,  far  safer  than  peroral  adminis- 
tration, for  it  overcomes  the  danger  of  respiratory  arrest  from 
pressure  of  the  esophagoscope,  foreign  body,  or  both,  on  the 
trachea.  Chloroform  should  not  be  used  for  esophagoscopy  or 
gastroscopy  because  of  its  depressant  action  on  the  respiratory 
center. 

For  bronchoscopy,  ether  or  chloroform  may  be  started  in  the 


05  BRONCHOSCOPY   AND   ESOPHAGOSCOPY 

usual  way  and  continued  by  insufflating  through  the  branch  tube 
of  the  bronchoscope  by  means  of  the  apparatus  shown  in  Fig.  13. 

In  case  of  paralysis  of  the  larynx,  even  if  only  monolateral, 
a  general  anesthetic  if  needed  should  be  given  by  intratracheal 
insufflation.  If  the  apparatus  for  this  is  not  available  the  patient 
should  be  tracheotomized.  Hence,  every  adult  patient  should  be 
examined  with  a  throat  mirror  before  general  anesthesia  for  any 
purpose,  and  the  necessity  becomes  doubly  imperative  before 
goiter  operations.  A  number  of  fatalities  have  occurred  from 
neglect  of  this  precaution. 

Anesthetizing  a  tracheotomized  patient  is  free  from  danger  so 
long  as  the  cannula  is  kept  free  from  secretion.  Ether  is  dropped 
on  gauze  laid  over  the  tracheotomic  cannula  and  the  anesthesia 
watched  in  the  usual  manner.  If  the  laryngeal  stenosis  is  not 
complete,  ether-saturated  gauze  is  to  be  placed  over  the  mouth  as 
well  as  over  the  tracheotomy  tube. 

Endo-tracheal  anesthesia  is  by  far  the  safest  way  for  the  adminis- 
tration of  ether  for  any  purpose.  By  means  of  the  silk-woven 
catheter  introduced  into  the  trachea,  ether-laden  air  from  an 
insufflation  apparatus  is  piped  down  to  the  lungs  continuously, 
and  the  strong  return-flow  prevents  blood  and  secretions  from 
entering  the  lower  air-passages.  The  catheter  should  be  of  a 
size,  relative  to  that  of  the  glottic  chink,  to  permit  a  free  return- 
flow.  A  number  24  French  is  readily  accommodated  by  the  adult 
larynx  and  lies  well  out  of  the  way  along  the  posterior  wall  of  the 
larynx.  Because  of  the  little  room  occupied  by  the  insufflation 
catheter  this  method  affords  ideal  anesthesia  for  external  laryngeal 
operations.  Operations  on  the  nose,  accessory  sinuses  and  the 
pharynx,  apt  to  be  attended  by  considerable  bleeding,  are  ren- 
dered free  from  the  danger  of  aspiration  pneumonia  by  endo- 
tracheal anesthesia.  It  is  the  safest  anesthesia  for  goiter 
operations.     Endo-tracheal  anesthesia  has  rendered  needless  the 


ANESTHESIA    FOR    PERORAL    EXDOSCOPY  69 

intricate  negative  pressure  chamber  formerly  required  for  thoracic 
surgery,  for  by  proper  regulation  of  the  pressure  under  which  the 
ether  ladened  air  is  delivered,  a  lung  may  be  held  in  any  desired 
degree  of  expansion  when  the  pleural  cavity  is  opened.  It  is 
indicated  in  operations  of  the  head,  neck,  or  thorax,  in  which 
there  is  danger  of  respiratory  arrest  by  centric  inhibition  or 
peripheral  pressure;  in  operations  in  which  there  is  a  possibiHty  of 
excessive  bleeding  and  aspiration  of  blood  or  secretions;  and  in 
operations  where  it  is  desired  to  keep  the  anesthetist  away  from 
the  operating  field.  Various  forms  of  apparatus  for  the  delivery 
of  the  ether-laden  vapor  are  supplied  by  instrument  makers  with 
explicit  directions  as  to  their  mechanical  management. 

We  are  concerned  here  mainly  with  the  technic  of  the  insertion 
of  the  intratracheal  tube.  The  larynx  should  be  examined  with 
the  mirror,  preferably  before  the  day  of  operation,  for  evidence  of 
disease,  and  incidentally  to  determine  the  size  of  the  catheter  to 
be  introduced,  though  the  latter  can  be  determined  after  the  larynx 
is  laryngoscopically  exposed.  The  following  list  of  rules  for  the 
introduction  of  the  catheter  will  be  of  service  (see  Fig.  59). 

RULES   FOR  INSERTION    OF   THE   CATHETER    FOR  INSUFFLATION 

ANESTHESIA 

1.  The  patient  should  be  fully  under  the  anesthetic  by  the 
open  method  so  as  to  get  full  relaxation  of  the  muscles  of  the  neck. 

2.  The  patient's  head  must  be  in  full  extension  with  the  vertex 
firmly  pushed  down  toward  the  feet  of  the  patient,  so  as  to  throw 
the  neck  upward  and  bring  the  occiput  down  as  close  as  possible 
beneath  the  cervical  vertebrae. 

3.  No  gag  should  be  used,  because  the  patient  should  be  suffi- 
ciently anesthetized  not  to  need  a  gag,  and  because  wide  gagging 
defeats  the  exposure  of  the  larynx  by  jamming  down  the  mandible. 

4.  The  epiglottis  must  be  identified  before  it  is  passed. 


yo  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

5.  The  speculum  must  pass  sufficiently  far  below  the  tip  of  the 
epiglottis  so  that  the  latter  will  not  slip. 

6.  Too  deep  insertion  must  be  avoided,  as  in  this  case  the 
speculum  goes  posterior  to  the  cricoid,  and  the  cricoid  is  lifted, 
exposing  the  mouth  of  the  esophagus,  which  is  bewildering  until 
sufficient  education  of  the  eye  enables  the  operator  to  recognize 
the  landmarks. 

7.  The  patient's  head  is  lifted  off  the  table  by  the  spatular  tip 
of  the  laryngoscope.  Actual  lifting  of  the  head  will  not  be  neces- 
sary if  the  patient  is  fully  relaxed;  but  the  idea  of  lifting  conveys 
the  proper  conception  of  laryngeal  exposure  (Fig.  55). 


CHAPTER  V 
BRONCHOSCOPIC  OXYGEN  INSUFFLATION 

Bronchoscopic  oxygen  insufliation  is  a  life-saving  measure 
equalled  by  no  other  method  known  to  the  science  of  medicine, 
in  all  cases  of  asphyxia,  or  apnea,  present  or  impending.  Its 
especial  sphere  of  usefulness  is  in  severe  cases  of  electric  shock, 
hanging,  smoke  asphyxia,  strangulation,  suffocation,  thoracic  or 
abdominal  pressure,  apnea,  acute  traumatic  pneumothorax, 
respiratory  arrest  from  absence  of  sulhcient  oxygen,  or  apnea 
from  the  presence  of  quantities  of  irrespirable  or  irritant  gases. 
Combined  with  bronchoscopic  aspiration  of  secretions  it  is  the 
best  method  of  treatment  for  poisoning  by  chlorine  gas,  asphyxiat- 
ing, and  other  war  gases. 

Bronchoscopic  oxygen  insufflation  should  be  taught  to  every 
interne  in  every  hospital.  The  emergency  or  accident  ward  of 
every  hospital  should  have  the  necessary  equipment  and  an  interne 
familiar  with  its  use.  The  method  is  simple,  once  the  knack  is 
acquired.  The  patient  being  limp  and  recumbent  on  a  table,  the 
larynx  is  exposed  with  the  laryngoscope,  and  the  bronchoscope  is 
inserted  as  hereinafter  described.  The  oxygen  is  turned  on  at  the 
tank  and  the  flow  regulated  before  the  rubber  tube  from  the  wash- 
bottle  of  tank  is  attached  to  the  side-outlet  of  the  bronchoscope. 
It  is  necessary  to  be  certain  that  the  flow  is  gentle,  so  that,  with  a 
free  return  flow  the  introduced  pressure  does  not  exceed  the  capil- 
lary pressure;  otherwise  the  blood  will  be  forced  out  of  the  capil- 
laries and  the  ischaemia  of  the  lungs  will  be  fatal.  Another 
danger  is  that  overdistension  causes  inhibition  of  inspiration 
resulting  in  apnea  continuing  as  long  as  the  distension  is  main- 

71 


72  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

tained,  if  not  longer.  The  return  flow  from  the  bronchoscope 
should  be  interrupted  for  2  or  3  seconds  several  times  a  minute 
to  inflate  the  lungs,  but  the  flow  must  not  be  occluded  longer  than 
3  seconds,  because  the  intrapulmonary  pressure  would  rise.  A 
pearl  of  amyl  nitrite  may  be  broken  in  the  wash  bottle.  Slow 
rhythmic  artificial  respiratory  movements  are  a  useful  adjunct,  and 
unless  the  operator  is  very  skillful  in  gauging  the  alternate  pres- 
sures and  releases  with  the  thumb  according  to  the  oxygen  pressure, 
it  is  vitally  necessary  to  fill  and  deflate  the  lungs  rhythmically  by 
one  of  the  well  known  methods  of  artificial  respiration.  Anyone 
skilled  in  the  introduction  of  the  bronchoscope  can  do  bronchos- 
copy in  a  few  seconds,  and  it  is  especially  easy  in  cases  of  respiratory 
arrest,  because  of  the  Hmp  condition  of  the  patient. 

The  foregoing  applies  to  cases  in  which  a  pulmotor  would  be 
used,  such  as  apnea  from  electric  shocks,  etc.  For  obstructive 
dyspnea  and  asphyxia,  tracheotomy  is  the  procedure  of  choice, 
and  the  skillful  tracheotomist  would  be  justified  in  preferring 
tracheotomy  for  the  other  class  of  cases,  insufflating  the  oxygen 
and  amyl  nitrite  through  the  tracheotomic  wound.  The  pul- 
motor and  similar  mechanisms  are,  perhaps,  the  best  things  the 
use  of  which  can  be  taught  to  laymen;  but  as  compared  to  bron- 
choscopic  oxygen  insufflation  they  are  woefully  inefficient,  because 
the  intraoral  pressure  forces  the  tongue  back  over  the  laryngeal 
orifice,  obstructing  the  airway  in  this  "death  zone."  By  the 
introduction  of  the  bronchoscope  this  death  zone  is  entirely  elimi- 
nated, and  a  free  airway  established  for  piping  the  oxygen  directly 
into  the  lungs. 


CHAPTER  VI 


POSITION  OF  THE  PATIENT  FOR  PERORAL 
ENDOSCOPY 


It  is  the  author's  invariable  prac- 
tice to  place  the  patient  in  the  dorsally 
recumbent  position.  The  sitting  posi- 
tion is  less  favorable.  While  lying  on 
a  well-padded,  flat  table  the  patient  is 
readily  controlled,  the  head  is  freely 
movable,  secretions  can  be  easily 
removed,  the  view  obtained  by  the 
endoscopist  is  truly  direct  (without 
reversal  of  sides),  and,  most  important, 
the  employment  of  one  position  only 
favors  smoother  and  more  efflcient  team 
work,  and  a  better  endoscopic  technic. 

General  Principles  of  Position. — As 
will  be  seen  in  Fig.  47  the  trachea  and 
esophagus  are  not  horizontal  in  the 
thorax,  but  their  long  axes  follow  the 
curves  of  the  cervical  and  dorsal  spine. 
Therefore,  if  we  are  to  bring  the  buccal 
cavity  and  pharynx  in  a  straight  line 
with  the  trachea  and  esophagus  it  will 
be  found  necessary  to  elevate  the  whole 
head  above  the  plane  of  the  table,  and 
at  the  same  time  make  extension  at  the 
occipito-atloid  joint.  By  this  maneu- 
ver the  cervical  spine  is  brought  in  line 
with  the  upper  portion  of    the  dorsal 

73 


Fig.  47. — Schematic  illus- 
tration of  normal  position  of 
the  intra-thoracic  trachea  and 
esophagus  and  also  of  the 
entire  trachea  when  the 
patient  is  in  the  correct  posi- 
tion for  peroral  bronchoscopy. 
When  the  head  is  thrown 
backward  (as  in  the  Rose 
position)  the  anterior  con- 
vexity of  the  cervical  spine 
is  transmitted  to  the  trachea 
and  esophagus  and  their  axes 
deviated.  The  anterior  devia- 
tion of  the  lower  third  of  the 
esophagus  shows  the  ana- 
tomical basis  for  the  "high 
low"  position  for  esophago- 
scopy 


74  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

spine  as  shown  in  Fig.  55.  It  was  formerly  taught,  and  often 
in  spite  of  my  better  knowledge  I  am  still  unconsciously 
prone  to  allow  the  head  and  cervical  spine  to  assume  a  lower 
position  than  the  plane  of  the  table,  the  so-called  Rose  posi- 
tion. With  the  head  so  placed,  it  is  impossible  to  enter  the  lower 
air  or  food  passages  with  a  rigid  tube,  as  will  be  shown  by  a  study 


Fig.  48. — Correct  position  of  the  cervical  spine  for  esophagoscopy  and  bron- 
choscopy. {Illiislration  reproduced  from  author's  article  Jour.  Am.  Med.  Assoc, 
Sept.  25,  1909  ) 

of  the  radiograph  shown  in  Fig.  49.  Extension  of  the  head  on  the 
occipito-atloid  joint  is  for  the  purpose  of  freeing  the  tube  from  the 
teeth,  and  the  amount  required  will  vary  with  the  degree  to  which 
the  mouth  can  be  opened.  Whether  the  head  be  extended,  flexed, 
or  kept  mid-way,  the  fundamental  principle  in  the  introduction  of 
all  endoscopic  tubes  is  the  anterior  placing  of  the  cervical  spine 
and  the  high  elevation  of  the  head.  The  esophagus,  just  behind 
the  heart,  turns  ventrally  and  to  the  left.  In  order  to  pass  a 
rigid  tube  through  this  ventral  curve  the  dorsal  spine  is  now  ex- 


POSITION    OF    THE    PATIENT    FOR    PERORAL    ENDOSCOPY 


75 


tended  by  lowering  the  head  and  shoulders  below  the  plane  of  the 
table.  This  will  be  further  explained  in  the  chapter  on  esophag- 
oscopy.  In  all  of  these  procedures,  the  nose  of  the  patient  should 
be  directed  toward  the  zenith,  and  the  assistant  should  prevent 
rotation  of  the  head  as  well  as  prevent  lowering  of  the  head.     The 


Fig.  4g — Curved  position  of  the  cervical  spine,  with  anterior  convexity,  in  the 
Rose  position,  rendering  esophagoscopy  and  bronchoscopj'  difficult  or  impossible. 
The'devious  course  of  the  pharj^nx,  larynx  and  trachea  are  plainly  visible.  The 
extension  is  incorrectly  imparted  to  the  whole  cervical  spine  instead  of  only  to  the 
occipito-atloid  Joint.  This  is  the  usual  and  very  faulty  conception  of  the  extended 
position.  {Illustration  reproduced  from  author's  article,  Jour.  Am.  Med.  Assoc, 
Sept.  25,  1909.) 

patient  should  be  urged  as  follows: 

"Don't  hold  yourself  so  rigid." 

"Let  your  head  and  neck  go  loose." 

"Let  your  head  rest  in  my  hand." 

"Don't  try  to  hold  it." 

"Let  me  hold  it." 

"Relax." 

"Don't  raise  your  chest." 


76 


BRONCHOSCOPY  AND  ESOPHAGOSCOPY 


For  direct  laryngoscopy  the  patient's  head  is  raised  above  the 
plane  of  the  table  by  the  first  assistant,  who  stands  to  the  right 
of  the  patient,  holding  the  bite  block  on  his  right  thumb  inserted 


Fig.  50. — Direct  laryngoscopy,  recumbent  patient.  The  second  assistant  is 
sitting  holding  the  head  in  the  Boyce  position,  his  left  forearm  on  his  left  thigh 
his  left  foot  on  a  stool  whose  top  is  65  cm.  lower  than  the  table-top.  His  left  hand  is 
on  the  patient's  sterile-covered  scalp,  the  thumb  on  the  forehead^  the  fingers  under 
the  occiput,  making  forced  extension.  The  right  forearm  passes  under  the  neck  of 
the  patient,  so  that  the  index  finger  of  the  right  hand  holds  the  bite-block  in  the 
left  corner  of  the  patient's  mouth.  The  fingers  of  the  operator's  right  hand  pulls  the 
upper  lip  out  of  all  danger  of  getting  pinched  between  the  teeth  and  the  larj-ngoscope. 
This  is  a  precaution  of  the  utmost  importance  and  the  trained  habit  of  doing  it 
must  be  developed  by  the  peroral  endoscopist. 


in  the  left  corner  of  the  patient's  mouth,  while  his  extended  right 
hand  lies  along  the  left  side  of  the  patient's  cheek  and  head,  and 
prevents  rotation.  His  left  hand,  placed  under  the  patient's 
occiput,  elevates  the  head  and  maintains  the  desired  degree  of 
extension  at  the  occipito-atloid  joint  (Fig.  50). 

Position  for  Bronchoscopy  and  Esophagoscopy. — The  dorsally 


POSITION   OF    THE   PATIENT   FOR   PERORAL   ENDOSCOPY 


77 


recumbent  patient  is  so  placed  that  the  head  and  shoulders  extend 
beyond  the  table,  the  edge  of  which  supports  the  thorax  at  about 
the  level  of  the  scapulae.     During  introduction,  the  head  must  be 


Fig.  5 1 . — Position  of  patient  and  assistant  for  introduction  of  the  bronchoscope 
and  esophagoscope.  The  middle  of  the  scapulae  rest  on  the  edge  of  the  table;  the 
Tiead  and  shoulder?,  free  to  move,  are  supported  by  the  assistant,  whose  right  arm 
passes  under  the  neck;  the  right  middle  finger  inserts  the  bite  block  into  the  left  side 
of  the  mouth.  The  left  hand,  resting  on  the  left  knee  maintains  the  desired  degree 
of  elevation,  extension  and  lateral  deflection  required  by  the  operator.  The  patient's 
vertex  should  be  lo  cm.  higher  than  the  level  of  the  top  of  the  table.  This  is  the 
Boyce  position,  which  has  never  been  improved  upon  for  bronchoscopy  and 
esophagoscopy. 


maintained  in  the  same  relative  position  to  the  table  as  that  de- 
scribed for  direct  laryngoscopy,  that  is,  elevated  and  extended. 
The  first  assistant,  in  this  case,  sits  on  a  stool  to  the  right  of  the 
patient's  head,  his  left  foot  resting  on  a  box  about  14  inches  in 
height,  the  left  knee  supporting  the  assistant's  left  hand,  which 
being  placed  under  the  occiput  of  the  patient  maintains  elevation 


78 


BRONCHOSCOPY   AND    ESOPHAGOSCOPY 


Chest  heaued 
2>pine  srchtd 


Fig.  52. — Schema  of  position  for  endoscopy. 

A.  Xormal  recumbency  on  the  table  with  pillow  supporting  the  head.  The 
larynx  can  be  directly  examined  in  this  position,  but  a  better  position  is  obtainable. 

B.  Head  is  raised  to  proper  position  with  head  flexed.  Muscles  of  front  of 
neck  are  relaxed  and  exposure  of  larynx  thus  rendered  easier;  but,  for  most  endo- 
scopic work,  a  certain  amount  of  extension  is  desired.  The  elevation  is  the  impor- 
tant thing. 

C.  The  neck  being  maintained  in  position  B,  the  desired  amount  of  extension  of 


POSITION    OF    THE    PATIENT    FOR    PERORAL    ENDOSCOPY  79 

and  extension.  The  right  arm  of  the  assistant  passes  under  the 
neck  of  the  patient,  the  bite  block  being  carried  on  the  middle 
finger  of  the  right  hand  and  inserted  into  the  left  side  of  the 
patient's  mouth.  The  right  hand  also  prevents  rotation  of  the 
head  (Fig.  51).  As  the  bronchoscope  or  esophagoscope  is  further 
inserted,  the  head  must  be  placed  so  that  the  tube  corresponds  to 
the  axis  of  the  lumen  of  the  passage  to  be  examined.  If  the  left 
bronchus  is  being  explored,  the  head  must  be  brought  strongly  to 
the  right.  If  the  right  middle  lobe  bronchus  is  being  searched, 
the  head  would  require  some  left  lateral  deflection  and  a  considerable 
degree  of  lowering,  for  this  bronchus,  as  before  mentioned, 
extends  anteriorly.  During  esophagoscopy  when  the  level  of  the 
heart  is  reached,  the  head  and  upper  thorax  must  be  strongly 
depressed  below  the  plane  of  the  table  in  order  to  follow  the  axis 
of  the  lumen  of  the  ventrally  turning  esophagus;  at  the  same 
time  the  head  must  be  brought  somewhat  to  the  right,  since  the 
esophagus  in  this  region  deviates  strongly  to  the  left. 

In  obtaining  the  position  of  high  head  with  occipito-atloid 
extension,  the  easiest  and  most  certain  method,  as  pointed  out  to 
me  by  my  assistant,  Gabriel  Tucker,  is  first  to  raise  the  head, 
strongly  flexed,  as  shown  in  Fig.  52;  then  while  maintaining  it 
there,  make  the  occipito-atloid  extension.  This  has  proven  better 
than  to  elevate  and  extend  in  a  combined  simultaneous  movement. 

If  the  patient  would  relax  to  limpness  exposure  of  the  larynx 


the  head  is  obtained  by  a  movement  limited  to  the  occipito-atloid  articulation  by  the 
assistant's  hand  placed  as  shown  by  the  dart  (B). 

D.  Faulty  position.  Unless  prevented,  almost  all  patients  will  heave  up  the 
chest  and  arch  the  lumbar  spine  so  as  to  defeat  the  object  and  to  render  endoscopy 
difficult  by  bringing  the  chest  up  to  the  high-held  head,  thus  assuming  the  same  rela- 
tion of  the  head  to  the  chest  as  exists  in  the  Rose  position  (a  faulty  one  for  endo- 
scopy) as  will  be  understood  by  assuming  that  the  dotted  line,  E,  represents  the 
table.  If  the  pelvis  be  not  held  down  to  the  table  the  patient  may  even  assume 
the  opisthotonous  position  by  supporting  his  weight  on  his  heels  on  the  table  and 
his  head  on  the  assistant's  hand. 


8o  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

would  be  easily  obtained,  simply  by  lifting  the  head  with  the  lip 
of  the  laryngoscope  passed  below  the  tip  of  the  epiglottis  (as  in 
Fig.  55)  and  no  holding  of  the  head  would  be  necessary.  But  only 
rarely  is  a  patient  found  who  can  do  this.  This  degree  of  relaxa- 
tion is  of  course,  present  in  profound  general  ether  anesthesia, 


Fig.  53. — The  author's  position  for  the  removal  of  foreign  bodies  from  the 
larynx  or  from  any  of  the  upper  air  or  food  passages.  If  dislodged,  the  intruder 
will  not  be  aided  by  gravity  to  reach  a  deeper  lodgement. 

which  is  not  to  be  thought  of  for  direct  laryngoscopy,  except  when 
it  is  used  for  the  purpose  of  insertion  of  intratracheal  insufflation 
anesthetic  tubes.  For  this,  of  course,  the  patient  is  already  to  be 
deeply  anesthetized.  The  muscular  tension  exerted  by  some  pa- 
tients in  assuming  and  holding  a  faulty  position  is  almost  as  much 
of  a  hindrance  to  peroral  endoscopy  as  is  the  position  itself.  The 
tendency  of  the  patient  to  heave  up  his  chest  and  assume  a  false 
position  simulating  the  opisthotonous  position  (Fig.  52)  must  be 


POSITION    OF    THE    PATIENT    FOR    PERORAL    ENDOSCOPY  8 1 

overcome  by  persuasion.     This  position  has  all  the  disadvantages 
of  the  Rose  position  for  endoscopy. 

The  one  exception  to  these  general  positions  is  found  in  pro- 
cedures for  the  removal  of  foreign  bodies  from  the  larynx.  In 
such  cases,  while  the  same  relative  position  of  the  head  to  the  plane 
of  the  table  is  maintained,  the  whole  table  top  is  so  inclined  as  to 
elevate  the  feet  and  lower  the  head,  known  as  Jackson's  position. 
This  semi-inversion  of  the  patient  allows  the  foreign  body  to  drop 
into  the  pharynx  if  it  should  be  dislodged,  or  slip  from  the  forceps 
(Fig.  53)- 


CHAPTER  VII 
DIRECT  LARYNGOSCOPY 

Importance  of  Mirror  Examination  of  the  Larynx. — The  pres- 
ence of  the  direct  laryngoscope  incites  spasmodic  laryngeal 
reflexes,  and  the  traction  exerted  somewhat  distorts  the  tissues, 
so  that  accurate  observations  of  variations  in  laryngeal  mobility 
are  difficult  to  obtain.  The  function  of  the  laryngeal  muscles 
and  structures,  therefore,  can  best  be  studied  with  the  laryngeal 
mirror,  except  in  infants  and  small  children  who  will  not  tolerate 
the  procedure  of  indirect  laryngoscopy.  A  true  idea  of  the  depth 
of  the  larynx  is  not  obtained  with  the  mirror,  and  a  view  of  the 
ventricles  is  rarely  had.  With  the  introduction  of  the  direct 
laryngoscope  it  is  found  that  the  larynx  is  funnel  shaped,  and  that 
the  adult  cords  are  situated  about  3  cm.  below  the  aryepiglottic 
folds;  the  cords  also  assume  their  true  shelf-like  character  and  take 
on  a  pinkish  or  yellowish  tinge,  rather  than  the  pearly  white  seen 
in  the  mirror.  They  are  not  to  any  extent  differentiated  by 
color  from  the  neighboring  structures.  Their  recognition  depends 
almost  wholly  on  form,  position  and  movement. 

Accurate  observation  is  stimulated  in  all  pathologic  cases  by 

making  colored  crayon  sketches,  however  crude,  of  the  mirror 

image  of  the  larynx.     The  location  of  a  growth  may  be  thus 

graphically  recorded,  so  that  at  the  time  of  operation  a  glance  will 

serve  to  refresh  the  memory  as  to  its  site.     It  is  to  be  constantly 

kept  in  mind,  however,  that  in  the  mirror  image  the  sides  are 

reversed  because  of  the  facing  positions  of  the  examiner  and 

patient.     Direct  laryngoscopy  is  the  only  method  by  which  the 

larynx  of  children  can  be  seen.    The  procedure  need  require  less 

than  a  minute  of  time,  and  an  accurate  diagnosis  of  the  condition 

82 


PLATE   II 


Direct  and  Indirect  Laryngeal  Views  from  Author's  Oil-color  Drawings 

FROM  Life: 

1,  Epiglottis  of  child  as  seen  by  direct  laryngoscopy  in  the  recumbent  position. 

2,  Normal  larynx  spasmodically  closed,  as  is  usual  on  first  exposure  without  anesthesia. 

3,  Same  on  inspiration.  4,  Su])raglottic  iia])illomata  as  seen  on  direct  lar>'ngoscopy  in 
a  child  of  two  j^ears.  5,  Cyst  of  the  larynx  in  a  child  of  four  years,  seen  on  direct 
laryngoscopy  without  anesthesia.  6.  Indirect  view  of  larynx  eight  weeks  after  thyrot- 
omy  foi  cancer  of  the  right  cord  in  a  man  of  fifty  years.  7,  Same  after  two  years.  An 
adventitious  band  indistinguishable  from  the  original  one  has  replaced  the  lost  cord. 
8.  Condition  of  the  larynx  three  years  after  hemilaryngectomy  for  ejjithelioma  in  a 
l)atient  fifty-one  years  of  age.  Thyrotomy  revealed  such  extensive  involvement,  with 
an  open  ulceration  which  had  reached  the  perichondrium,  that  the  entire  left  wing  of 
the  thyroid  cartilage  was  removed  with  the  left  arytenoid.  .\  sufiiciently  wide  removal 
was  accomplished  without  remo\ing  any  part  of  the  esophageal  wall  below  the  level 
of  the  crico-arytenoid  joint.  There  is  no  attempt  on  the  part  of  nature  to  form  an 
adventitious  cord  on  the  left  side.  The  normal  arytenoid  drew  the  normal  cord  over, 
approximately  to  the  edge  of  the  cicatricial  tissue  of  the  operated  side.  The  voice,  at 
first  a  very  hoarse  whisper,  eventually  was  fairly  loud,  though  slightly  husky  and  in- 
flexible. 9,  The  pharynx  seen  one  year  after  laryngectomy  for  endothelioma  in  a 
man  aged  sixty-eight  years.  The  puri>le  papillae  anteriorly  are  at  the  base  of  the  tongue, 
and  from  this  the  mucosa  slopes  downward  and  backward  smoothly  into  the  esophagus. 
There  are  some  slight  folds  toward  the  left  and  some  of  these  are  quite  cicatricial. 
The  epiglottis  was  removed  at  operation.  The  trachea  was  sutured  to  the  skin  and 
did  not  communicate  with  the  pharynx.     (Direct  view.) 


DIRECT    LARYXGOSCOPY  83 

present,  whether  papilloma,  foreign  body,  diphtheria,  paralysis, 
etc.,  may  be  thus  obtained.  The  posterior  pharyngeal  wall 
should  be  examined  in  all  dyspneic  children  for  the  possible 
existence  of  retropharyngeal  abscess. 

Contraindications  to  Direct  Laryngoscopy. — There  are  no 
absolute  contraindications  to  direct  laryngoscopy  in  any  case 
where  direct  laryngoscopy  is  really  needed  for  diagnosis  or  treat- 
ment. In  extremely  dyspneic  patients,  if  the  operator  is  not 
confident  in  his  ability  for  a  prompt  and  sure  introduction  of  a 
bronchoscope,  it  may  be  wise  to  do  a  tracheotomy  first. 

Instructions  to  the  Patient. — Before  beginning  endoscopy  the 
patient  should  be  told  that  he  will  feel  a  very  disagreeable  pressure 
on  his  neck  and  that  he  may  feel  as  though  he  were  about  to  choke. 
He  must  be  gently  but  positively  made  to  understand  (i)  that 
while  the  procedure  is  alarming,  it  is  absolutely  free  from  danger; 
(2)  that  you  know  just  how  it  feels;  (3)  that  you  will  not  allow  his 
breath  to  be  shut  off  completely;  (4)  that  he  can  help  you  and 
himself  very  much  by  paying  close  attention  to  breathing  deeply 
and  regularly;  (5)  and  that  he  must  not  draw  himself  up  rigidly 
as  though  "walking  on  ice,"  but  must  be  easy  and  relaxed. 

Direct  Laryngoscopy.  Adult  Patient. — Before  starting,  every 
detail  in  regard  to  instrumental  equipment  and  operating  room 
assistants,  (including  an  assistant  to  hold  the  arms  and  legs  of  the 
patient)  must  be  complete.  Preparation  of  the  patient  and  the 
technic  of  local  anesthesia  have  been  discussed  in  their  respective 
chapters.  The  dorsally  recumbent  patient  is  draped  with  (not 
pinned  in)  a  sterile  sheet.  The  head,  covered  by  sterile  towels,  is 
elevated,  and  slight  extension  is  made  at  the  occipitoatloid  joint 
by  the  left  hand  of  the  first  assistant.  The  bite  block  placed  on 
the  assistant's  right  thumb  is  inserted  into  the  left  angle  of  the 
patient's  open  mouth  (see  Fig.  50). 

The  laryngoscope  must  always  and  invariably  be  held  in  the 


84 


BRONCHOSCOPY  AND  ESOPHAGOSCOPY 


left  hand,  and  in  such  a  manner  that  the  greatest  amount  of  trac- 
tion is  made  at  the  swell  of  the  horizontal  bar  of  the  handle,  rather 
than  on  the  vertical  bar. 

The  right  hand  is  then  free  for  the  manipulation  of  forceps, 
and  the  insertion  of  the  bronchoscope  or  other  instrument. 
During  introduction,  the  fingers  of  the  right  hand  retract  the 
upper  lip  so  as  to  prevent  its  being  pinched  between  the  laryn- 
goscope and  the  teeth.  The  introduction  of  the  direct  laryngoscope 
and  exposure  of  the  larynx  is  best  described  in  two  stages. 

1 .  Exposure  and  identification  of  the  epiglottis. 

2.  Elevation  of  the  epiglottis  and  all  the  tissues  attached 
to  the  hyoid  bone,  so  as  to  expose  the  larynx  to  direct  view. 

First  Stage. — The  spatular  end  of  the  laryngoscope  is  intro- 
duced in  the  right  side  of  the  patient's  mouth,  along  the  right  side 

of  the  anterior  two-thirds  of  the  tongue. 
It  was  the  German  method  to  introduce 
the  laryngoscope  over  the  dorsum  of  the 
tongue  but  in  order  to  elevate  this 
sometimes  powerful  muscular  organ 
considerable  force  may  be  required, 
which  exercise  of  force  may  be  entirely 
avoided  by  crowding  the  tongue  over 
to  the  left.  When  the  posterior  third 
of  the  tongue  is  reached,  the  tip  of  the 
laryngoscope  is  directed  toward  the 
midline  and  the  dorsum  of  the  tongue 
is  elevated  by  a  lifting  motion  imparted 
to  the  laryngoscope.  The  epiglottis 
will  then  be  seen  to  project  into  the  endoscopic  field,  as  seen 
in  Fig.  54. 

Second  Stage. — The  spatular  end  of  the  laryngoscope  should 
now  be  tipped  back  toward  the  posterior  wall  of  the  pharynx, 


Fig.  54. — End  of  the  first 
stage  of  direct  laryngoscopy, 
recumbent  adult  patient.  The 
epiglottis  is  exposed  by  a  lift- 
ing motion  of  the  spatular  tip 
on  the  tongue  anterior  to  the 
epiglottis. 


DIRECT    LARYNGOSCOPY 


85 


passed  posterior   to   the  epiglottis,   and  advanced   about   i   cm. 
The  larynx  is  now  exposed  by  a  motion  that  is  best  described  as  a 


Fig.  55. — Schema  illustrating  the  technic  of  direct  laryngoscopy  on  the  recum- 
bent patient  The  motion  is  imparted  to  the  tip  of  the  laryngoscope  as  if  to  lift 
the  patient  by  his  hyoid  bone.  The  portion  of  the  table  indicated  by  the  dotted  line 
may  be  dropped  or  not,  but  the  back  of  the  head  must  never  go  lower  than  here 
shown,  for  direct  laryngoscopy;  and  it  is  better  to  have  it  at  least  10  cm.  above  the 
level  of  the  table.  The  table  may  be  used  as  a  rest  for  the  operator's  left  elbow  to 
take  the  weight  of  the  head.  (Note  that  in  bronchoscopy  and  esophagoscopy  the 
head  section  of  the  table  must  be  dropped,  so  as  to  leave  the  head  and  neck  of  the 
patient  out  in  the  air,  supported  by  the  second  assistant.) 

suspension  of  the  head  and  all  the  structures  attached  to  the 
hyoid  bone  on  the  tip  of  the  spatular  end  of  the  laryngoscope 
(Fig.  55).  Particular  care  must  be  taken  at  this  stage  not  to  pry 
on  the  upper  teeth;  but  rather  to  impart  a  lifting  motion  with 


86 


BRO^XHOSCOPY    AND    ESOPHAGOSCOPY 


the  tip  of  the  speculum  without  depressing  the  proximal  tubular 
orifice.  It  is  to  be  emphasized  that  while  some  pressure  is  neces- 
sary in  the  lifting  motion,  great  force  should  never  be  used;  the 
art  is  a  gentle  one.  The  first  view  is  apt  to  find  the  larynx  in 
state  of  spasm,  and  affords  an  excellent  demonstration  of  the  fact 
that  the  larynx  can  be  completely  closed  without  the  aid  of  the 

epiglottis.  Usually  little  more  is  seen 
than  the  two  rounded  arytenoid  masses, 
and,  anterior  to  them,  the  ventricular 
bands  in  more  or  less  close  apposition 
hiding  the  cords  (Fig.  56).  With  deep 
general  anesthesia  or  thorough  local 
anesthesia  the  spasm  may  not  be  pres- 
ent. By  asking  the  patient  to  take  a 
,-       r     ,-   .  deep    breath    and    maintain    stead v 

Jig.  56. — Lndoscopic  view      ^^^i;'     "  ^^'-       ^•-•■^     ±i^,^i,.±±i.k.ka,i...±     ^^.^^l^^^J 

at  the  end  of  the  second  stage    breathing,  or  perhaps  by  requesting  a 

of  direct  laryngoscopy.      Re-        ,  <-r  i        1  •^^ 

cumbent  patient.    Larynx    phonatory  effort,  the  larynx  will  open 
exposed  waiting  for  larynx    widely  and  the  cords  be  revealed.     If 

to  relax  its   spasmodic    con-  .  .  r    1      i 

traction  ^^^  anterior  commissure  of  the  larynx 

is  not  readily  seen,  the  lifting  motion 
and  elevation  of  the  head  should  be  increased,  and  if  there  is 
still  difficulty  in  exposing  the  anterior  commissure  the  assistant 
holding  the  head  should  with  the  index  finger  externally  on  the 
neck  depress  the  thyroid  cartilage.  If  by  this  technic  the  larynx 
fails  to  be  revealed  the  endoscopist  should  ask  himself  which 
of  the  following  rules  he  has  violated. 


RULES  FOR  DIRECT  LARYNGOSCOPY 


1.  The  laryngoscope  must  always  be  held  in  the  left  hand, 
never  in  the  right. 

2.  The  operator's  right  index  finger  (never  the  left)  should 


DIRECT    LARYNGOSCOPY  87 

be  used  to  retract  the  patient's  upper  lip  so  that  there  is  no  danger 
of  pinching  the  lip  between  the  instrument  and  the  teeth. 

3.  The  patient's  head  must  always  be  exactly  in  the  middle 
line,  not  rotated  to  the  right  or  left,  nor  bent  over  sidewise;  and 
the  entire  head  must  be  forward  with  extension  at  the  occipito- 
atloid  joint  only. 

4.  The  laryngoscope  is  inserted  to  the  right  side  of  the  anterior 
two-thirds  of  the  tongue,  the  tip  of  the  spatula  being  directed 
toward  the  midline  when  the  posterior  third  of  the  tongue  is 
reached. 

5.  The  epiglottis  must  always  be  identified  before  any  attempt 
is  made  to  expose  the  larynx. 

6.  When  first  inserting  the  laryngoscope  to  find  the  epiglottis, 
great  care  should  be  taken  not  to  insert  too  deeply  lest  the  epiglot- 
tis be  overridden  and  thus  hidden. 

7.  After  identification  of  the  epiglottis,  too  deep  insertion  of 
the  laryngoscope  must  be  carefully  avoided  lest  the  spatula  be 
inserted  back  of  the  arytenoids  into  the  hypo-pharynx. 

8.  Exposure  of  the  larynx  is  accomplished  by  pulling  forward 
the  epiglottis  and  the  tissues  attached  to  the  hyoid  bone,  and  not 
by  prying  these  tissues  forward  with  the  upper  teeth  as  a  fulcrum. 

9.  Care  must  be  taken  to  avoid  mistaking  the  ary-epiglottic 
fold  for  the  epiglottis  itself.  (Most  likely  to  occur  as  the  result  of 
rotation  of  the  patient's  head.) 

10.  The  tube  should  not  be  retained  too  long  in  place,  but  should 
be  removed  and  the  patient  permitted  to  swallow  the  accumulated 
saliva,  which,  if  the  laryngoscope  is  too  long  in  place,  will  trickle 
down  the  trachea  and  cause  cough.  (Swallowing  is  almost  impos- 
sible while  the  laryngoscope  is  in  position.)  The  secretions  may  be 
removed  with  the  aspirator. 

11.  The  patient  must  be  instructed  to  breathe  deeply  and 
quietly  without  making  a  sound. 


55  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

Difficulties  of  Direct  Laryngoscopy. — The  larynx  can  be  directly 
exposed  in  any  patient  whose  mouth  can  be  opened,  although  the 
ease  varies  greatly  with  the  type  of  patient.  Failure  to  expose  the 
epiglottis  is  usually  due  to  too  great  haste  to  enter  the  speculum 
all  the  way  down.  The  spatula  should  glide  slowly  along  the 
posterior  third  of  the  tongue  until  it  reaches  the  glossoepiglottic 
fossa,  while  at  the  same  time  the  tongue  is  lifted;  when  this  is 
done  the  epiglottis  will  stand  out  in  strong  relief.  The  beginner 
is  apt  to  insert  the  speculum  too  far  and  expose  the  hypopharynx 
rather  than  the  larynx.  The  elusiveness  of  the  epiglottis  and  its 
tendency  to  retreat  downward  are  very  much  accentuated  in 
patients  who  have  worn  a  tracheotomic  cannula;  and  if  still 
wearing  it,  the  patient  can  wait  indefinitely  before  opening  his 
glottis.  Over  extension  of  the  patient's  head  is  a  frequent  cause 
of  difficulty.  If  the  head  is  held  high  enough  extension  is  not 
necessary,  and  the  less  the  extension  the  less  muscular  tension 
there  is  in  the  anterior  cervical  muscles.  Only  one  arytenoid 
eminence  may  be  seen.  The  right  and  the  left  look  different. 
Practice  will  facilitate  identification,  so  that  the  endoscopist  will 
at  once  know  which  way  to  look  for  the  glottis. 

Of  the  difficulties  that  pertain  to  the  operator  himself  the 
greatest  is  lack  of  practice.  He  must  learn  to  recognize  the  land- 
marks even  though  a  high  degree  of  spasm  be  present.  The 
epiglottis  and  the  two  rounded  eminences  corresponding  to  the 
arytenoids  must  be  in  the  mind's  eye,  for  it  is  only  on  deep,  relaxed 
inspiration  that  anything  Hke  a  typical  picture  of  the  larynx  will 
be  seen.  He  must  know  also  the  right  from  the  left  arytenoid 
when  only  one  is  seen  in  order  to  know  whether  to  move  the  lip  of 
the  laryngoscope  to  the  right  or  the  left  for  exposure  of  the  interior 
of  the  larynx. 

Instruments  for  Direct  Laryngoscopy. — In  undertaking  direct 
laryngoscopy  one  must  always  be  prepared  for  bronchoscopy. 


DIRECT    LARYNGOSCOPY  89 

esophagoscopy,  and  tracheotomy,  as  well.  Preparations  for 
bronchoscopy  are  necessary  because  the  pathological  condition 
may  not  be  found  in  the  larynx,  and  further  search  of  the  trachea 
or  bronchi  may  be  required.  A  foreign  body  in  the  larynx  may 
be  aspirated  to  a  deeper  location  and  could  only  be  followed  with 
the  bronchoscope.  Sudden  respiratory  arrest  might  occur,  from 
pathology  or  foreign  body,  necessitating  the  inserting  of  the 
bronchoscope  for  breathing  purposes,  and  the  insufflation  of 
oxygen  and  amyl  nitrite.  Trachectomy  might  be  required  for 
dyspnea  or  other  reasons.  It  might  be  necessary  to  explore  the 
esophagus  for  conditions  associated  with  laryngeal  lesions,  as 
for  instance  a  foreign  body  in  the  esophagus  causing  dyspnea  by 
pressure.  In  short,  when  planning  for  direct  laryngoscopy,, 
bronchoscopy,  or  esophagoscopy,  prepare  for  all  three,  and 
for  tracheotomy.  A  properly  done  direct  laryngoscopy  would 
never  precipitate  a  tracheotomy  in  an  unanesthetized  patient; 
but  direct  laryngoscopy  has  to  deal  so  frequently  with  laryngeal 
stenosis,  that  routine  preparation  for  tracheotomy  a  hundred 
unnecessary  times  is  fully  compensated  for  by  the  certainty  of 
preparedness  when  the  rare  but  urgent  occasion  arises. 

Direct  Laryngoscopy  in  Children. — The  epiglottis  in  children 
is  usually  strongly  curled,  often  omega  shaped,  and  is  very  elusive 
and  slippery.  The  larynx  of  a  child  is  very  freely  movable  in  the 
neck  during  respiration  and  deglutition,  and  has  a  strong  tendency 
to  retreat  downward  during  examination,  and  thus  withdraw  the 
epiglottis  after  the  arytenoids  have  been  exposed.  In  following 
down  with  the  laryngoscope  the  speculum  is  prone  to  enter  the 
hypopharynx.  Lifting  in  this  location  will  expose  the  mouth  of 
the  esophagus  and  shut  off  the  larynx,  and  may  cause  respiratory 
arrest.  Practice,  however,  will  soon  develop  a  technic  and  ability 
to  recognize  the  landmarks  in  state  of  spasm,  so  that  on  exposing 
the  approximated  arytenoid  eminences  the  endoscopist  will  main- 


90  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

tain  his  position  and  wait  for  the  larynx  to  open.  The  procedure 
should  be  done  without  any  form  of  anesthesia  for  the  following 
reasons: 

1.  Anesthesia  is  unnecessary. 

2.  It  is  extremely  dangerous  in  a  dyspneic  patient. 

3.  It  is  inadmissable  in  a  patient  with  diphtheria. 

4.  If  anesthesia  is  to  be  used,  direct  laryngoscopy  will  never 
reach  its  full  degree  of  usefulness,  because  anesthesia  makes  a 
major  procedure  out  of  a  minor  one. 

5.  Cocain  in  children  is  dangerous,  and  its  application  more 
annoying  than  the  examination. 

Inducing  a  Child  to  Open  its  Mouth  {Author ^s  Method). — The 
wounding  of  the  child's  mouth,  gums,  and  lips,  in  the  often  ineffi- 
cacious methods  with  gags,  hemostats,  raspatories,  etcetera,  are 
entirely  unnecessary.  The  mouth  of  any  child  not  unconscious 
can  be  opened  quickly  and  without  the  slightest  harm  by  passing 
a  curved  probe  between  the  clenched  jaws  back  of  the  molars  and 
down  back  of  the  tongue  toward  the  laryngopharynx.  This 
will  cause  the  child  to  gag,  when  its  mouth  invariably  opens. 


CHAPTER  VIII 
DIRECT  LARYNGOSCOPY   {Continued) 

Technic  of  Laryngeal  Operations. — Preparation  of  the  patient 
and  anesthesia  have  been  mentioned  under  their  respective 
chapters.  The  prime  essential  of  successful  laryngeal  operations 
is  perfect  mastery  of  continuous  left-handed  laryngeal  exposure. 
The  right  hand  must  be  equally  trained  in  the  manipulation  of 
forceps,  and  the  right  eye  to  gauge  depth.  Blood  and  secretions 
are  best  removed  by  a  suction  tube  (Fig.  9)  inserted  through 
the  laryngoscope,  or  directly  into  the  pharynx  outside  the 
laryngoscope. 

For  the  removal  of  benign  growths  the  author's  papilloma  forceps. 
Fig.  29,  or  the  laryngeal  grasping  forceps  shown  in  Fig.  17  will 
prove  more  satisfactory  than  any  form  of  cutting  forceps.  These 
growths  should  be  removed  superficially  flush  with  the  normal 
structure.  The  crushing  of  the  base  incident  to  the  plucking  off 
of  the  growth  causes  its  recession.  By  this  conservative  method 
damage  to  the  cords  and  impairment  of  the  voice  are  avoided. 
For  growths  in  the  anterior  portion  of  the  larynx,  and  in  fact  for 
the  removal  of  most  small  benign  growths,  the  anterior  commissure 
laryngoscope  is  especially  adapted.  Its  shape  allows  its  introduc- 
tion into  the  vestibule  of  the  larynx,  and  if  desired  it  may  be 
introduced  through  the  glottic  chink  for  the  treatment  of  sub- 
glottic conditions.  It  will  not  infrequently  be  observed  that  a 
pedunculated  subglottic  growth  which  is  found  with  difficulty 
will  be  pulled  upward  into  view  by  the  gauze  swab  introduced  to 
remove  secretions.  The  growth  is  then  often  held  tightly  between 
the  approximated  cords  for  a  few  seconds — perhaps  long  enough 
to  grasp  it  with  forceps. 

91 


92 


BRONCHOSCOPY  AND  ESOPHAGOSCOPY 


Removal  of  Growth  from  the  Laryngeal  Ventricle. — After  expos- 
ing the  larynx  in  the  usual  manner,  if  the  head  is  turned  strongly 
to_the  right,  the  tip  of  the  laryngoscope,  directed  from  the  right 


Fig.  57. — Schema  illustrating  the  lateral  method  of  exposing  a  growth  in  the 
ventricle  of  Morgagni,  by  bending  the  patient's  head  to  the  opposite  side,  while  the 
second  assistant  externally  fixes  the  larynx  with  his  hand.  M,  Patient's  mouth; 
T,  thyroid  cartilage;  R,  right  side;  L,  left.  V,  B,  ventricular  band.  C,  C,  vocal 
cord.  The  circular  drawing  indicates  the  endoscopic  view  obtainable  by  this 
method.  The  tube,  E,  is  dropped  to  the  corner  of  the  mouth,  B,  and  the  tube 
is  inserted  down  to  R.  The  lip  of  the  spatula  can  then  be  used  to  lift  the  ven- 
tricular band  so  as  to  expose  more  of  the  ventricle.  The  drawing  shows  an  unusu- 
ally shallow  ventricle. 


side  of  the  mouth,  may  be  used  to  lift  the  left  ventricular  band 
and  thus  expose  the  ventricle,  from  which  a  growth  may  be  re- 
moved in  the  usual  manner  (Fig.  57).  The  right  ventricle  is 
exposed  by  working  from  the  left  side  of  the  mouth. 

Taking  a  Laryngeal  Specimen  for  Diagnosis. — The  diagnosis 
of  carcinoma,  sarcoma,  and  some  other  conditions  can  be  made 


DIRECT    LARYNGOSCOPY 


93 


r 


certain  only  by  microscopic  study  of  tissue  removed  from  the 
growth.  The  specimen  should  be  ample 
but  will  necessarily  be  small.  If  the 
suspected  growth  be  small  it  should  be 
removed  entire,  together  with  some  of 
the  basal  tissues.  If  it  is  a  large  growth, 
and  there  are  objections  to  its  entire 
removal,  the  edge  of  the  growth,  includ- 
ing apparently  normal  as  well  as  neo- 
plastic tissue,  is  necessary.  If  it  is  a 
diffuse  infiltrative  process,  a  specimen 
should  be  taken  from  at  least  two  loca- 
tions. Tissue  for  biopsy  is  to  be  taken 
with  the  punch  forceps  shown  in  Fig.  28 
or  that  in  Fig.  33.  The  forceps  may  be 
inserted  through  the  tube  or  from  the 
angle  of  the  mouth;  the  "extubal" 
method  (see  Fig.  58). 

Removal  of  large  henign  tumors  above 
the  cords  may  be  done  with  the  snare 
•or  with  the  large  laryngeal  punch  for- 
ceps. Both  are  used  in  the  extubal 
miethod. 

Amputation  of  the  epiglottis  for  pallia- 
tion of  odynphagia  or  dysphagia  in  tuber- 
culous or  malignant  disease,  is  of  benefit 
when  the  ulceration  is  confined  to  this 
region;  though  as  to  tuberculosis  the 
author  feels  rather  conservatingly 
inclined.     Early     malignancy     of     the 

extreme  tip  can  be  cured  by  such  means.     The  function  of  the 
-epiglottis  seems  to  be  to  split  the  food  bolus  and  direct  its  por- 


) 


Fig.  58. — Schema  illus- 
trating removal  of  a  tumor 
from  the  upper  part  of  the 
larynx  by  the  author's  "ex- 
tubal" method  for  large 
tumors.  The  large  alhgator 
basket  punch  forceps,  F,  is 
inserted  from  the  right 
corner  of  the  mouth,  and 
the  jaws  are  placed  over 
the  tumor  T,  under  guid- 
ance of  the  eye  looking 
through  the  laryngoscope, 
L.  This  method  is  not  used 
for  small  tumors.  It  is 
excellent  for  amputation  of 
the  epiglottis  with  these 
same  punch  forceps  or  with 
the  heavy  snare. 


94  BROXCHOSCOPY  AND  ESOPHAGOSCOPY 

tions  laterally  into  the  pyriform  sinuses,  rather  than  to  take  any 
important  part  in  the  closure  of  the  larynx.  Following  the 
removal  of  the  epiglottis  there  is  rarely  complaint  of  food  enter- 
ing the  larynx.  The  projecting  portion  of  the  epiglottis  may  be 
amputated  with  a  heavy  snare,  or  by  means  of  the  large  laryngeal 
punch  forceps  (Fig.  33). 

Endoscopic  Operations  for  Laryngeal  Stenosis. — Web  formations 
may  be  excised  with  sliding  punch  forceps,  or  if  the  web  is  due  to 
contraction  only,  incision  of  the  true  band  may  allow  its  retraction. 
In  some  instances  liberation  of  adhesions  will  favor  the  formation 
of  adventitious  vocal  cords.  A  sharp  anterior  commissure  is  a 
large  factor  in  good  phonation. 

Endoscopic  evisceration  of  the  larynx  will  cure  a  few  cases  of 
laryngeal  cicatricial  stenosis,  and  should  be  tried  before  resorting 
to  laryngostomy.  A  sliding  punch  forceps  is  used  to  remove  all 
the  tissue  in  the  larynx  out  to  the  perichondrium,  but  care  should 
be  taken  in  cicatricial  cases  to  avoid  removing  any  part  of  either 
arytenoid  cartilage.  In  cases  of  posticus  paralysis  the  excision 
may  include  portions  of  the  vocal  processes  of  the  arytenoids. 
Ventriculocordectomy  is  preferable  to  evisceration.  The  ventricu- 
lar floor  is  removed  with  punch  forceps  (Fig.  33)  first  on  one 
side,  then  after  two  months,  on  the  other. 

Vocal  Results. — A  whispering  voice  can  always  be  had  as  long 
as  air  can  pass  through  the  larynx,  and  this  may  be  developed  to 
a  very  loud  penetrating  stage  whisper.  If  the  arytenoid  motility 
has  been  uninjured  the  repeated  pulls  on  the  scar  tissue  may  draw 
out  adventitious  bands  and  develop  a  loud,  useful,  though  perhaps 
rough  and  inflexible  voice. 

Galvano-cauterization  is  the  best  method  of  treatment  for 
chronic  subglottic  edema  or  hyperplasia  such  as  is  seen  in  children 
following  diphtheria,  when  the  stenosis  produced  prevents  extuba- 
tion  or  decannulation.     The  utmost  caution  should  be  used  to 


DIRECT    LARYNGOSCOPY  95 

avoid  deep  cauterizations;  they  are  almost  certain  to  set  up  peri- 
chondritis which  will  increase  the  stenosis.  Some  of  the  most 
difficult  cases  that  have  come  to  the  author  have  been  previously- 
cauterized  too  deeply. 

Galva  no-cautery  puncture  of  tuberculous  inliltrations  of  the 
larynx  at  times  yields  excellent  results  in  cases  with  mild  pul- 
monary lesions,  and  has  quite  replaced  the  use  of  the  curette, 
lactic  acid,  and  other  caustics.  The  direct  method  of  exposing 
the  larynx  renders  the  application  of  the  cautery  point  easy  and 
accurate.  In  severely  stenosed  tuberculous  larynges  a  tracheot- 
omy should  first  be  done,  for  though  the  reaction  is  slight  it 
might  be  sufficient  to  close  a  narrowed  glottis.  The  technic  is  the 
usual  one  for  laryngeal  operations.  Local  anesthesia  suffices. 
The  larynx  is  exposed.  The  rheostat  having  been  previously 
adjusted  to  heat  the  electrode  to  nearly  white  heat,  the  circuit 
is  broken  and  the  electrode  introduced  cold.  When  the  point 
is  in  contact  with  the  desired  location  the  current  is  turned  on  and 
the  point  thrust  in  as  deeply  as  desired.  Usually  it  should  pene- 
trate until  a  firm  resistance  is  felt;  but  care  must  be  used  not  to 
damage  the  cricoarytenoid  joint.  The  circuit  is  broken  at  the 
instant  of  withdrawal.  Punctures  should  be  made  as  nearly  as 
possible  perpendicular  to  the  surface,  so  as  to  minimize  the  destruc- 
tion of  epithelium  and  thus  lessen  the  reaction.  A  minute  gray 
fibrous  slough  detaches  itself  in  a  few  days.  Cautery  puncture 
should  be  repeated  every  two  or  three  weeks,  selecting  a  new 
location  each  time,  until  the  desired  result  is  obtained.  Great 
caution,  as  mentioned  above,  must  be  used  to  avoid  setting  up 
perichondritis.  Many  cases  of  laryngeal  tuberculosis  will  recover 
as  quickly  by  silence  and  a  general  antituberculous  regime. 

Radium,  in  form  of  capsules  or  of  needles  inserted  in  the  tissues 
may  be  applied  with  great  accuracy;  but  the  author  is  strongly 
impressed  with  pyriform  sinus  applications  by  the  Freer  method. 


^6  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

After-care  of  endolaryngeal  operations  includes  careful  cleansing 
■of  the  teeth  and  mouth;  and  if  the  extrinsic  area  of  the  larynx  is 
involved  in  the  wound,  sterile  liquid  food  and  water  should  be 
given  for  four  days.  The  patient  should  be  watched  for  complica- 
tions by  a  special  nurse  who  is  familiar  with  the  signs  of  laryngeal 
dyspnea  (q.v.).  Complications  during  endolaryngeal  operations 
are  rare.  Dyspnea  may  require  tracheotomy.  Idiosyncrasy  to 
cocain,  or  the  sight  or  taste  of  blood  may  nauseate  the  patient  and 
cause  syncope.  Serious  hemorrhage  could  occur  only  in  a  hemo- 
phile.  The  careless  handling  of  a  bite  block  might  damage  a  frail 
tool  or  dental  fixture. 

Complications  after  endolaryngeal  operations  are  unusual. 
•Carelessness  in  asepsis  has  been  known  to  cause  cervical  cellulitis. 
Emphysema  of  the  neck  has  occurred.  Edema  of  the  larynx 
occasionally  occurs,  and  might  necessitate  tracheotomy.  Serious 
bleeding  after  operation  is  very  rare  except  in  bleeders.  Hemor- 
rhage within  the  larynx  can  be  stopped  by  the  introduction  of  a  roll 
of  gauze  from  above,  tracheotomy  having  been  previously  per- 
formed. Morphin  subcutaneously  administered,  has  a  constricting 
action  on  the  vessels  which  renders  it  of  value  in  controUing 
hemorrhage. 


CHAPTER  IX 

INTRODUCTION  OF  THE  BRONCHOSCOPE 

No  one  should  do  bronchoscopy  until  he  is  able  to  expose  the 
glottis  by  left-handed  direct  laryngoscopy  in  less  than  one  minute. 
When  he  has  mastered  this,  one  minute  more  should  be  sufficient  to 
introduce  the  bronchoscope  into  the  trachea. 

TECHNIC  OF  BRONCHOSCOPY 

Local  anesthesia  is  usually  employed  in  the  adult.     The  patient 


Fig.  59. — Insufflation  anesthesia  with  Elsberg  apparatus.  Anesthetist  has 
exposed  the  larynx  and  is  about  to  introduce  the  silk-woven  catheter.  Note  the 
full  extension  of  the  head  on  the  table. 

is  placed  in  the  Boyce  position  shown  in  Fig.  51,  with  head  and 

shoulders  projecting  over  the  edge  of  the  table  and  supported  by 

7  97 


98 


BRONCHOSCOPY  AND  ESOPHAGOSCOPY 


an  assistant.     The  glottis  is 


Fig.  6o/ — Schema  illustrating 
the  introduction  of  the  broncho- 
scope through  the  glottis,  recum- 
bent patient.  The  handle,  H,  is 
always  horizontally  to  the  right. 
When  the  glottis  is  first  seen 
through  the  tube  it  should  be 
centrally  located  as  at  K.  At  the 
next  inspiration  the  end  B,  is 
moved  horizontally  to  the  left  as 
shown  by  the  dart,  M,  until  the 
glottis  shows  at  the  right  edge  of 
the  field,  C.  This  means  that  the 
point  of  the  lip,  B,  is  at  the  med- 
ian line,  and  it  is  then  quickly 
(not  violently)  pushed  through 
into  the  trachea.  At  this  same 
moment  or  the  instant  before, 
the  hyoid  bone  is  given  a  quick 
additional  lift  with  the  tip  of  the 
laryngoscope. 


exposed  by  left-handed  laryngoscopy. 
The  instrument-assistant  now  inserts 
the  distal  end  of  the  bronchoscope 
into  the  lumen  of  the  laryngoscope, 
the  handle  being  directed  to  the  right 
in  a  horizontal  position.  The  opera- 
tor now  grasps  the  bronchoscope,  his 
eye  is  transferred  from  the  laryngo- 
scope to  the  bronchoscope,  and  the 
bronchoscope  is  advanced  and  so 
directed  that  a  good  view  of  the 
glottis  is  obtained.  The  slanted  end 
of  the  bronchoscope  should  then  be 
directed  to  the  left,  so  as  clearly  to 
expose  the  left  cord.  In  this  posi- 
tion it  will  be  found  that  the  tip  of 
the  slanted  end  is  in  the  center  of  the 
glottic  chink  and  will  slip  readily  into 
the  trachea.  No  great  force  should 
be  used,  because  if  the  bronchoscope 
does  not  go  through  readily,  either 
the  tube  is  too  large  a  size  or  it 
is  not  correctly  placed  (Fig.  60). 
Normally,  however,  there  is  some 
slight  resistance,  which  in  cases  of 
subglottic  laryngitis  may  be  consider- 
able. The  trained  laryngologist  will 
readily  determine  by  sense  of  touch 
the  degree  of  pressure  necessary  to 
overcome  it.  When  the  broncho- 
scope has  been  inserted  to  about 
the  second  or    third    tracheal   ring. 


INTRODUCTION    OF    THE   BRONCHOSCOPE 


99 


the  heavy  laryngoscope  is  removed 
by  rotating  the  handle  to  the  left, 
removing  the  slide,  and  withdrawing 
the  instrument.  Care  must  be  taken 
that  the  bronchoscope  is  not  with- 
drawn or  coughed  out  during  the 
removal  of  the  laryngoscope;  this 
can  be  avoided  by  allowing  the  ocular 
end  to  rest  against  the  gown-covered 
chest  of  the  operator.  If  preferred 
the  operator  may  train  his  instru- 
mental assistant  to  take  off  the 
laryngoscope,  while  the  operator 
devotes  his  attention  to  prevent- 
ing the  withdrawal  of  the  broncho- 
scope by  holding  the  handle  with 
his  right  hand.  At  the  moment  of 
insertion  of  the  bronchoscope  through 
the  glottis,  an  especially  strong 
upward  lift  on  the  beak  of  the 
spatula  will  facilitate  the  passage. 
It  is  necessary  to  be  certain  that 
the  axis  of  the  bronchoscope  corre- 
sponds to  the  axis  of  the  trachea,  in 

Fig.  6r. — Schema  illustrating  oral  broncho- 
scopy. The  portion  of  the  table  here  shown 
under  the  head  is,  in  actual  work,  dropped  all 
the  way  down  perpendicularly.  It  appears  in 
these  drawings  as  a  dotted  line  to  emphasize  the 
fact  that  the  head  must  be  above  the  level  of 
the  table  during  introduction  of  the  broncho- 
scope into  the  trachea  A,  Exposure  of  larynx; 
B,  bronchoscope  introduced;  C,  slide  removed; 
D,  laryngoscope  removed  leaving  bronchoscope 
alone  in  position. 


Fig.  6i. 


lOO  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

order  to  avoid  injury  to  the  subglottic  tissue  which  might  be 
followed  by  subglottic  edema  (Fig.  47).  If  the  subglottic  region 
is  already  edematous  and  causes  resistance,  slight  rotation  to 
the  laryngoscope,  and  bronchoscope  will  cause  the  bronchoscope 
to  enter  more  easily. 

Difficulties    in    the    Introduction    of    the    Bronchoscope. — The 


Fig  62. — Insertion  of  the  bronchoscope.  Note  direction  of  the  trachea  as  indi- 
cated by  the  bronchoscope.  Note  that  the  patient's  head  is  held  above  the  level  of 
the  table.  The  assistant's  left  hand  should  be  at  the  patient's  mouth  holding  the 
bite-block.  This  is  removed  and  the  assistant  is  on  the  wrong  side  of  the  table  in  the 
illustration  in  order  not  to  hide  the  position  of  the  operator's  hands.  Note  the 
handle  of  the  bronchoscope  is  to  the  right. 


beginner  may  enter  the  esophagus  instead  of  the  trachea:  this 
might  be  a  dangerous  accident  in  a  dyspneic  case,  for  the  tube 
could,  by  pressure  on  the  trachea,  cause  respiratory  arrest.  A 
bronchoscope  thus  misplaced  should  be  resterilized  before  intro- 
ducing it  into  the  air  passages,  for  while  the  lower  air  passages  are 
usually  free  from  bacteria,  the  esophagus  is  a  septic  canal.     If  the 


INTRODUCTION    OF    THE   BRONCHOSCOPE 


lOI 


given  technic  is  carefully  carried  out  the  bronchoscope  will  not  be 
contaminated  with  mouth  secretions.  The  trachea  is  recognized 
as  an  open  tube,  with  whitish  rings,  and  the  expiratory  blast  can 


Fig.  63. — The  heavy  laryngoscope  has  been  removed  leaving  ihe  light  broncho- 
scope in  position  The  operator  is  inserting  forceps.  Note  how  the  left  hand  of  the 
operator  holds  the  tube  lightly  between  the  thumb  and  first  two  fingers  of  the  left 
hand,  while  the  last  two  fingers  are  hooked  over  the  upper  teeth  of  the  patient 
"anchoring"  the  tube  to  prevent  it  moving  in  or  out  or  otherwise  changing  the 
relation  of  the  distal  tube-mouth  to  a  foreign  body  or  a  growth  while  forceps  are 
being  used.  Thus,  also,  any  desired  location  of  the  tube  can  be  maintained  in 
systematic  exploration.  The  assistant's  left  hand  is  dropped  out  of  the  way  to 
show  the  operator's  method.  The  assistant  during  bronchoscopy  holds  the  bite- 
block  like  a  thimble  on  the  index  finger  of  the  left  hand,  and  the  assistant  should  be 
on  the  right  side  of  the  patient.  He  is  here  put  wrongly  on  the  left  side  so  as  not  to 
hide  the  instruments  and  the  manner  of  holding  them. 

be  felt  and  tubular  breathing  heard;  while  if  by  mistake  the 
bronchoscope  has  entered  the  gullet  it  will  be  observed  that  the 
cervical  esophagus  has  collapsed  walls.  A  pufif  of  air  may  be 
felt  and  a  fluttering  sound  heard  when  the  tube  is  in  the  esophagus, 
but  these  lack  the  intensity  of  the  tracheal  blast.  Usually  a 
free  flow  of  secretion  is  met  with  in  the  esophagus.     In  diseased 


[■-[{\  ^  ic 


I02  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

states  the  tracheal  rings  may  not  be  visible  because  of  swollen 
mucosa,  or  the  trachea  itself  may  be  in  partial  collapse  from 
external  pressure.  The  true  expiratory  blast  will,  however,  always 
be  recognized  when  the  tube  is  in  the  trachea.  Wide  gagging  of 
the  mouth  renders  exposure  of  the  larynx  difficult. 

Examination  of  the  Trachea  and  Bronchi. — All  bronchial  orifices 
must  be  identified  seriatim;  because  this  is  the  only  way  by  which 


A  B 

Fig.  64. — At  A  is  shown  an  incorrect  manner  of  holding  the  bronchoscope.  The 
grasp  is  too  rigid  and  the  position  of  the  hand  is  awkward.  B,  Correct  manner,  the 
collar  being  held  lightly  between  the  finger  and  the  thumb  The  thumb  must  not 
occlude  the  tube  mouth. 


the  bronchoscopist  can  know  what  part  of  the  tree  he  is  examining. 
Appearances  alone  are  not  enough.  It  is  the  order  in  which  they 
are  exposed  that  enables  the  inexperienced  operator  to  know  the 
orifices.  After  the  removal  of  the  laryngoscope,  the  bronchoscope 
is  to  be  held  by  the  left  hand  like  a  bilHard  cue,  the  terminal 
phalanges  of  the  left  middle  and  ring  fingers  hooking  over  the 
upper  teeth,  while  the  thumb  and  index  finger  hold  the  broncho- 
scope, clamping  it  to  the  teeth  tightly  or  loosely  as  required 
(Fig.  63).  Thus  the  tube  may  be  anchored  in. any  position,  or 
at  any  depth,  and  the  right  hand  which  was  directing  the  tube 
may  be  used  for  the  manipulation  of  instruments.  The  grasp  of 
the  bronchoscope  in  the  right  hand  should  be  similar  to  that  of 
holding  a  pen,  that  is,  the  thumb,  first,  and  second  fingers,  encircle 


■'  \  ?i  ','  l-f  1 

J   -  T'  I'  /      ',■  n  J 


INTRODUCTION    OF    THE    BRONCHOSCOPE  IO3 

the  shaft  of  the  tube.  The  bronchoscope  should  never  be  held 
by  the  handle  (Fig.  64)  for  this  grasp  does  not  allow  of  tactile 
sense  transmission,  is  rigid,  awkward,  and  renders  rotation  of 
the  tube  a  wrist  motion  instead  of  but  a  gentle  finger  action. 
Any  secretion  in  the  trachea  is  to  be  removed  by  sponge  pumping 
before  the  bronchoscope  is  advanced.  The  inspection  of  the 
walls  of  the  trachea  is  accomplished  by  weaving  from  side  tp  side 
and,  if  necessary,  up  and  down;  the  head  being  deni^cted'  als"'*" 
required  during  the  search  of  the  passages,  so  that  the  larynx 
be  not  made  the  fulcrum  in  the  lever-like  action. 

The  Fulcrum  of  the  Bronchoscopic  Lever  is  at  the  Upper  Thoracic 
Aperture;  Never  at  the  Larynx. — Disregard  of  this  rule  will  cause 
subglottic  edema  and  will  limit  the  lateral  motion  of  the  tip  of  the 
bronchoscope.  It  is  the  function  of  the  assistant  to  make  the 
head  and  neck  follow  the  direction  of  the  proximal  end  of  the  bron- 
choscope and  thus  avoid  any  pressure  on  the  larynx  (see  Peroral 
Endoscopy,  Fig.  135,  p.  164). 

In  passing  down  the  trachea  the  following  two  rules  must  be 
kept  in  mind: 

1.  Before  attempting  to  enter  either  main  bronchus  the  carina 
must  be  identified. 

2.  Before  entering  either  main  bronchus  the  orifices  of  both 
should  be  identified  and  inspected. 

The  carina  is  identified  as  a  sharp  vertical  spur  (recumbent 
patient)  at  the  distal  end  of  the  trachea,  on  either  side  of  which  are 
the  openings  of  the  main  bronchi.  As  the  carina  is  situated  to  the 
left  of  the  midline  of  the  trachea,  the  lip  of  the  bronchoscope  should 
be  turned  toward  the  left,  and  slight  lateral  pressure  should  be 
made  on  the  left  tracheal  wall  while  the  head  of  the  patient  is 
held  slightly  to  the  right.  This  will  expose  the  left  bronchial 
orifice  and  carina. 

Entering  the  Bronchi. — The  lip  of  the  bronchoscope  should  be 


I04 


BRONCHOSCOPY  AND  ESOPHAGOSCOPY 


turned  in  the  direction  of  the  bronchus  to  be  explored,  and  the  axis 
of  the  bronchoscope  should  be  made  to  correspond  as  nearly  as 
possible  to  the  axis  of  this  bronchus.  The  position  of  the  lip  is 
designated  by  the  direction  taken  by  the  handle.  Upon  entering 
the  right  bronchus,  the  handle  of  the  bronchoscope  is  turned  hori- 
zontally to  the  right,  and  at  the  same  time  the  assistant  deflects 
the  head  to  the  left. 

The  right  upper-lobe  bronchus  is  recognized  by  its  vertical 


0 


TT 


Fig.  65. — Schema  illustrating  the  entering  of  the  anteriorlj'  branching  middle 
lobe  bronchus.  T,  Trachea;  B,  orifice  of  left  main  bronchus  at  bifurcation  of 
trachea.  The  bronchoscope,  S,  is  in  the  right  main  bronchus,  pointing  in  the 
direction  of  the  right  inferior  lobe  bronchus,  I.  In  order  to  cause  the  lip  to  enter  the 
middle  lobe  bronchus,  M,  it  is  necessary  to  drop  the  head  so  that  the  bronchoscope 
in  the  trachea  TT,  will  point  properly  to  enable  the  lip  of  the  tube  mouth  to  enter  the 
middle  lobe  bronchus,  as  it  is  seen  to  have  done  at  ML. 


spur ;  the  orifice  is  exposed  by  displacing  the  right  lateral  wall  of  the 
right  main  bronchus  at  the  level  of  the  carina.  Usually  this  orifice 
will  be  thus  brought  into  view.  If  not  the  bronchoscope  may  be 
advanced  downward  i  or  2  cm.,  carefully  to  avoid  overriding. 
This  branch  is  sometimes  found  coming  off  the  trachea  itself,  and 
even  if  it  does  not,  the  overriding  of  the  orifice  is  certain  if  the 


INTRODUCTION  OF  THE  BRONCHOSCOPE  105 

right  bronchus  is  entered  before  search  is  made  for  the  upper-lobe- 
bronchial  orifice.  The  head  must  be  moved  strongly  to  the  left 
in  order  to  view  the  orifice.  A  lumen  image  of  the  right  upper- 
lobe  bronchus  is  not  obtainable  because  of  the  sharp  angles  at 
which  it  is  given  off.  The  left  upper-lobe  bronchus  is  entered  by 
keeping  the  handle  of  the  bronchoscope  (and  consequently  the  lip) 
to  the  left,  and,  by  keeping  the  head  of  the  patient  strongly  to  the 
right  as  the  bronchoscopist  goes  down  the  left  main  bronchus. 
This  causes  the  lip  of  the  bronchoscope  to  bear  strongly  on  the  left 
wall  of  the  left  main  bronchus,  consequently  the  left  upper-lobe- 
bronchial  orifice  will  not  be  overridden.  The  spur  separating 
the  upper-lobe-bronchial  orifice  from  the  stem  bronchus  is  at  an 
angle  approximately  from  two  to  eight  o'clock,  as  usually  seen 
in  the  recumbent  patient.  A  lumen  image  of  a  descending  branch 
of  the  upper-lobe  bronchus  is  often  obtained,  if  the  patient's  head 
be  borne  strongly  enough  to  the  right. 

Branches  of  the  stem  bronchus  in  either  lung  are  exposed,  or 
their  respective  lumina  presented,  by  manipulation  of  the  lip  of 
the  bronchoscope,  with  movement  of  the  head  in  the  required 
direction.  Posterior  branches  require  the  head  quite  high.  A 
large  one  in  the  left  stem  just  below  the  left  upper-lobe  bronchus  is 
often  invaded  by  foreign  bodies.  Anterior  branches  require 
lowering  the  head.  The  middle-lobe  bronchus  is  the  largest  of  all 
anterior  branches.  Its  almost  horizontal  spur  is  brought  into 
view  by  directing  the  lip  of  the  bronchoscope  upward,  and  drop- 
ping the  head  of  the  patient  until  the  lip  bears  strongly  on  the 
anterior  wall  of  the  right  bronchus  (see  Fig.  65). 


CHAPTER  X 
INTRODUCTION  OF  THE  ESOPHAGOSCOPE 

The  esophagoscope  is  to  be  passed  only  with  ocular  guidance, 
never  blindly  with  a  mandrin  or  obturator,  as  was  done  before 
the  bevel-ended  esophagoscope  was  developed.  Blind  introduction 
of  the  esophagoscope  is  equally  as  dangerous  as  blind  bouginage. 
It  is  almost  certain  to  cause  over-riding  of  foreign  bodies  and 
disease.  In  either  condition  perforation  of  the  esophagus  is 
possible  by  pushing  a  sharp  foreign  body  through  the  normal  wall 
or  by  penetrating  a  wall  weakened  by  disease.  Landmarks  must 
be  identified  as  reached,  in  order  to  know  the  locality  reached. 
The  secretions  present  form  sufficient  lubrication  for  the  instru- 
ment. A  clear  conception  of  the  endoscopic  anatomy,  the 
narrowings,  direction,  and  changes  of  direction  of  the  axis  of  the 
esophagus,  are  necessary.  The  services  of  a  trained  assistant  to 
place  the  head  in  the  proper  sequential  "high-low"  positions  are 
indispensible  (Figs.  52  and  70).  Introduction  may  be  divided 
into  four  stages. 

1.  Entering  the  right  pyriform  sinus. 

2.  Passing  the  cricopharyngeus. 

3.  Passing  through  the  thoracic  esophagus. 

4.  Passing  through  the  hiatus. 

The  patient  is  placed  in  the  Boyce  position  as  described  in 
Chapter  VI.  As  previously  stated,  the  esophagus  in  its  upper 
portion  follows  the  curves  of  the  cervical  and  dorsal  spine.  It  is 
necessary,  therefore,  to  bring  the  cervical  spine  into  a  straight 
line  with  the  upper  portion  of  the  dorsal  spine  and  this  is  accom- 
plished by  elevation  of  the  head — the  "high"  position  (Figs. 
66-71). 

106 


PLATE  III 

EsopHAGoscopic  Views  from  Oil-color  Dra^vtngs  from  Life,  by  the  Author: 

I,  Direct  view  of  the  larynx  and  laryngopharynx  in  the  dorsally  recumbent  patient, 
the  epiglottis  and  hyoid  bone  being  lifted  with  the  direct  laryngoscope  or  the  esophageal 
speculum.  The  spasmodically  adducted  vocal  cords  are  partially  hidden  by  the  over- 
hang of  the  spasmodically  prominent  ventricular  bands.  Posterior  to  this  the  aryep- 
iglottic  folds  ending  posteriorly  in  the  arytenoid  eminences  are  seen  in  apposition. 
The  esophagoscope  should  be  passed  to  the  right  of  the  median  line  into  the  right 
pyriform  sinus,  represented  here  by  the  right  arm  of  the  dark  crescent.  2,  The  right 
pyriform  sinus  in  the  dorsally  recumbent  patient,  the  eminence  at  the  upper  left 
border,  corresponds  to  the  edge  of  the  cricoid  cartilage.  3,  The  cricopharyngeal  con- 
striction of  the  esophagus  in  the  doraslly  recumbent  patient,  the  cricoid  cartilage  being 
lifted  forward  with  the  esophageal  speculum.  The  lower  (posterior)  half  of  the  lumen 
is  closed  by  the  fold  corresponding  to  the  orbicular  fibers  of  the  cricopharyngeus  which 
advances  spasmodically  from  the  posterior  wall.  (Compare  Fig.  10.)  This  view  is 
not  obtained  with  an  esophagoscope.  4,  Passing  through  the  right  pyriform  sinus  with 
the  esophagoscope;  dorsally  recumbent  patient.  The  walls  seem  in  tight  apposition, 
and,  at  the  edges  of  the  slit-like  lumen,  bulge  toward  the  obser\-er.  The  direction  of 
the  axis  of  the  slit  varies,  and  in  some  instances  it  is  like  a  rosette,  depending  on  the 
degree  of  spasm.  5,  Cervical  esophagus.  The  lumen  is  not  so  patulent  during  ins[)ira- 
tion  as  lower  down;  and  it  closes  completely  during  expiration.  6,  Thoracic  esophagus; 
dorsally  recumbent  patient.  The  ridge  crossing  above  the  lumen  corresponds  to  the 
left  bronchus.  It  is  seldom  so  prominent  as  in  this  patient,  but  can  always  be  found  if 
searched  for.  7,  The  normal  esophagus  at  the  hiatus.  This  is  often  mistaken  for  the 
cardia  by  esophagoscopists.  It  is  more  truly  a  sphincter  than  the  cardia  itself.  In  the 
author's  opinion  there  is  no  truly  sphincteric  action  at  the  cardia.  It  is  the  failure  of 
this  hiatal  sphincter  to  open  as  in  the  normal  deg'.utitory  cycle  that  produces  the 
syndrome  called  "cardiospasm."  8,  View  in  the  stomach  with  the  open-tube  gastro- 
scope.  The  form  of  the  folds  varies  continually.  9,  Sarcoma  of  the  posterior  wall  of 
the  upper  third  of  the  esophagus  in  a  woman  of  thirty-one  years.  Seen  through  the 
esophageal  speculum,  patient  sitting.  The  lumen  of  the  mouth  of  the  esophagus,  much 
encroached  upon  by  the  sarcomatous  infiltration,  is  seen  at  the  lower  part  of  the  circle. 
10,  Coin  (half-dollar)  wedged  in  the  upper  third  of  the  esophagus  of  a  boy  aged  fourteen 
years.  Seen  through  the  esophageal  speculum,  recumbent  patient.  Forceps  are  re- 
tracting the  posterior  lip  of  the  esophageal  "mouth"  preparatory  to  removal.  11, 
Fungating  squamous-celled  epithelioma  in  a  man  of  seventy-four  years.  Fungations 
are  not  always  present,  and  are  often  pale  and  edematous.  12,  Cicatricial  stenosis  of 
the  esophagus  due  to  the  swallowing  of  lye  in  a  boy  of  four  years.  Below  the  upper 
stricture  is  seen  a  second  stricture.  An  ulcer  surrounded  by  an  inflammatory  areola 
and  the  granulation  tissue  together  illustrates  the  etiology  of  cicatricial  tissue.  The 
fan-shaped  scar  is  really  almost  linear,  but  it  is  viewed  in  perspective.  Patient 
was  cured  by  esophagoscopic  dilatation.  13,  Angioma  of  the  esophagus  in  a  man  of 
forty  years.  The  patient  had  hemorrhoids  and  varicose  veins  of  the  legs.  14,  Luetic 
ulcer  of  the  esojjhagus  26  cm.  from  the  upper  teeth  in  a  woman  of  thirty-eight  years. 
Two  scars  from  healed  ulcerations  are  seen  in  perspective  on  the  anterior  wall.  Branch- 
ing vessels  are  seen  in  the  livid  areola  of  the  ulcers.  15,  Tuberculosis  of  the  esophagus 
in  a  man  of  thirty-four  years.  16,  Leukoplakia  of  the  esophagus  near  the  hiatus  in  a 
man  aged  fifty-six  years. 


PLATE  III 


5  6  7  8 

ESOPHAGOSCOPIC    VIEWS.   NORMAL. 


13  14  15  16 

ESOPHAGOSCOPIC  VIEWS .  ABNORMAL. 


INTRODUCTION  OF  THE  ESOPHAGOSCOPE  107 

The  hypopharynx  tapers  down  to  the  gullet  like  a  funnel, 
and  the  larynx  is  suspended  in  its  lumen  from  the  anterior  wall. 
The  larynx  is  attached  only  to  the  anterior  wall,  but  is  held  closely 
against  the  posterior  pharyngeal  wall  by  the  action  of  the  inferior 
constrictor  of  the  pharynx,  and  particularly  by  its  specialized 
portion — the  cricopharyngeus  muscle.  A  bolus  of  food  is  split 
by  the  epiglottis  and  the  two  portions  drifted  laterally  into  the 
pyriform  sinuses,  the  recesses  seen  on  either  side  of  the  larynx. 
But  little  of  the  food  bolus  passes  posterior  to  the  larynx  during 
the  act  of  swallowing.  It  is  through  the  pyriform  sinus  that  the 
esophagoscope  is  to  be  inserted,  thereby  following  the  natural 
food  passage.  To  insert  the  esophagoscope  in  the  midline,  pos- 
terior to  the  arytenoids,  requires  a  degree  of  force  dangerous  to 
exert  and  almost  certain  to  produce  damage  to  the  cricoarytenoid 
joint  or  to  the  pharyngeal  wall,  or  to  both. 

The  esophagoscope  is  steadied  by  the  left  hand  like  a  billard 
cue,  the  terminal  phalanges  of  the  left  middle  and  ring  jfingers 
hooked  over  the  upper  teeth,  while  the  left  index  finger  and  thumb 
encircle  the  tube  and  retract  the  upper  lip  to  prevent  its  being 
pinched  between  the  tube  and  upper  teeth.  The  right  hand  holds 
the  tube  in  pen  fashion  at  the  collar  of  the  handle,  not  by  the 
handle.  During  introduction  the  handle  is  to  be  pointed  upward 
toward  the  zenith. 

Stage  I.  Entering  the  Right  Pyriform  Sinus. — The  operator 
standing  (as  in  Fig.  66),  inserts  the  esophagoscope  along  the  right 
side  of  the  tongue  as  far  as  and  down  the  posterior  pharyngeal 
wall.  A  lifting  motion  imparted  to  the  tip  of  the  esophagoscope 
by  the  left  thumb  will  bring  the  rounded  right  arytenoid  eminence 
into  view  (A,  Fig.  69).  This  is  the  landmark  of  the  pyriform 
sinus,  and  care  must  be  taken  to  avoid  injury  by  hooking  the  tube 
mouth  over  it  or  its  fellow.  The  tip  of  the  tube  should  now  be 
directed  somewhat  toward  the  midline,  remembering  the  funnel 


Io8  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

shape  of  the  hypopharynx.  It  will  then  be  found  to  glide  readily 
through  the  right  pyriform  sinus  for  2  or  3  cm.,  when  it  comes  to 
a  full  stop,  and  the  lumen  disappears.  This  is  the  spasmodically 
closed  cricopharyngeal  constriction. 


Fig.  66. — Esophagoscopy  by  the  author's  "high-low"  method.  First  stage. 
"High"  position.  Finding  the  right  pyriform  sinus.  In  this  and  the  second  stage 
the  patient's  vertex  is  about  15  cm.  above  the  level  of  the  table. 


Stage  2.  Passing  the  cricopharyngeus  is  the  most  difficult 
part  of  esophagoscopy,  especially  if  the  patient  is  unanesthetized. 
Local  anesthesia  helps  little,  if  at  all.  The  handle  of  the  esopha- 
goscope  is  still  pointing  upward  and  consequently  we  are  sure  that 
the  lip  of  the  esophagoscope  is  directed  anteriorly.  Force  must 
not  be  used,  but  steady  firm  pressure  against  the  tonically  con- 
tracted cricopharyngeus  is  made,  while  at  the  same  time  the  distal 
end  of  the  esophagoscope  is  lifted  by  the  left  thumb.     At  the  first 


INTRODUCTION  OF  THE  ESOPHAGOSCOPE 


109 


/Veck 


Fig.  67. — Schematic  illustration  of  the  author's  "high-low"  method  of  esoph- 
agoscopy.  In  the  first  and  second  stages  the  patient's  head  fully  extended  is  held 
high  so  as  to  bring  it  in  line  with  the  thoracic  esophagus,  as  shown  above.  The 
Rose  position  is  shown  by  way  of  accentuation. 


Gricoici- 


P/riform  sinus 

CricojaliarYn; 

geu5 

(I'lif.  constrictor') 

Cervlcfll 
&bine 


Direction  of 
cricoid  JDi-essure 

Cncaicr  cartlhgt 
Cricojoliari'ngeus 


L50\)}\QQQ- 

scO|be- 


,.  .Perforation 
^V'.'lfiiminent 


Fig.  68 — Schematic  illustration  of  the  anatomic  basis  for  difficulty  in  introduc- 
tion of  the  esophagoscope.  The  cricoid  cartilage  is  pulled  backward  against 
the  cervical  spine,  by  the  cricopharyngeus,  so  strongly  that  it  is  difficult  to 
realize  that  the  cricopharyngeus  is  not  inserted  into  the  vertebral  periosteum  instead 
of  into  the  median  raphe. 


no 


BRONCHOSCOPY  AND  ESOPHAGOSCOPY 


inspiration  a  lumen  will  usually  appear  in  the  upper  portion 
of  the  endoscopic  field.     The  tip  of  the  esophagoscope  enters  this 


F?i_gKt  lia,-ul  abciOc 

tuakci  fji-cssuie  and  also 

t  olio  MS  tnoMemcTits   of 
left  thu  ni  b 


Left  hartd. 


Danger  of 
p&rtoYacLon    here- 

Crlco|ahai'im^eus  ynusc^lc^  blocit 
insertion,  of  e&ijfjhagosco/^fc 


Fig.  69  ■ — The  upper  illustration  shows  movements  necessary  for  passing  the 
cricopharyngeus. 

The  lower  illustration  shows  schematically  the  method  of  finding  the  pyriform 
sinus  in  the  author's  method  of  esophagoscopy.  The  large  circle  represents  the 
cricoid  cartilage.  G,  Glottic  chink,  spasmodically  closed;  VB,  ventricular  band; 
A,  right  arytenoid  eminence;  P,  rght  pyriform  sinus,  through  which  the  tube  is 
passed  in  the  recumbent  posture.  The  pyriform  sinuses  are  the  normal  food 
passages. 


lumen  and  the  slanted  end  slides  over  the  fold  of  the  cricopharyn- 
geus into  the  crevical  esophagus.  There  is  usually  from  i  to  3 
cm.  of  this  constricted  lumen  at  the  level  of  the  cricopharyngeus 
and  the  subjacent  orbicular  esophageal  fibers. 


INTRODUCTION  OF  THE  ESOPHAGOSCOPE 


III 


Stage  3.  Passmg  Through  the  Thoracic  Esophagus. — The  tho- 
racic esophagus  will  be  seen  to  expand  during  inspiration  and  con- 
tract during  expiration,  due  to  the  change  in  thoracic  pressure. 
The  esophagoscope  usually  glides  easily  through  the  thoracic 
esophagus  if  the  patient's  position  is  correct.  After  the  levels  of 
the  aorta  and  left  bronchus  are  passed  the  lumen  of  the  esophagus 
seems  to  have  a  tendency  to  disappear  anteriorly.  The  lumen 
must  be  kept  in  axial  view  and  the  head  lowered  as  required  for 
this  purpose. 

Stage  4.  Passing  Through  the  Hiatus  Esophageus. — When  the 
head  is  dropped,  it  must  at  the  same  time  be  moved  horizontally 


Fig.  70. — Schematic  illustration  of  the  author's  "high-low"  method  of  esoph- 
agoscopy,  fourth  stage.  Passing  the  hiatus.  The  head  is  dropped  from  the  position 
of  the  I  St  and  2nd  stages,  CL,  to  the  position  T,  and  at  the  same  time  the  head  and 
shoulders  are  moved  to  the  right  (without  rotation)  which  gives  the  necessary 
direction  for  passing  the  hiatus. 

to  the  right  in  order  that  the  axis  of  the  tube  shall  correspond  to  the 
axis  of  the  lower  third  of  the  esophagus,  which  deviates  to  the 
left  and  turns  anteriorly.  The  head  and  shoulders  at  this  time 
will  be  found  to  be  considerably  below  the  plane  of  the  table  top 
(Fig.  71).  The  hiatal  constriction  may  assume  the  form  of  a  slit 
or  rosette.  If  the  rosette  or  slit  cannot  be  promptly  found,  as 
may  be  the  case  in  various  degrees  of  diffuse  dilatation,  the  tube 


112  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

mouth  must  be  shifted  farther  to  the  left  and  anteriorly.  When 
the  tube  mouth  is  centered  over  the  hiatal  constriction  moderately- 
firm  pressure  continued  for  a  short  time  will  cause  it  to  yield. 
Then  the  tube,  maintaining  this  same  direction  will,  without 
further  trouble  glide  into  and  through  the  abdominal  esophagus. 


Fig.  ti.- — Esophagoscopy  by  the  author's  " high-low "  method.     Stage  4.     Passing 
the  hiatus      The  patient's  vertex  is  about  5  cm.  below  the  top  of  the  table. 

The  cardia  will  not  be  noticed  as  a  constriction,  but  its  appearance 
will  be  announced  by  the  rolhng  in  of  reddish  gastric  mucosal  folds, 
and  by  a  gush  of  fluid  from  the  stomach. 

Normal  esophageal  mucosa  under  proper  illumination  is  glisten- 
ing and  of  a  yellowish  or  bluish  pink.  The  folds  are  soft  and 
velvety,  rendering  infiltration  quickly  noticeable.  The  cricoid 
cartilage  shows  white  through  the  mucosa.  The  gastric  mucosa 
is  a  darker  pink  than  that  of  the  esophagus  and  when  actively 
secreting,  its  color  in  some  cases  tends  toward  crimson. 

Secretions  in  the  esophagus  are  readily  aspirated  through  the 


INTRODUCTION    OF    THE    ESOPHAGOSCOPE  II3 

drainage  canal  by  a  negative  pressure  pump.  Food  particles 
are  best  removed  by  "sponge  pumping,"  or  with  forceps.  Should 
the  drainage  canal  become  obstructed  positive  pressure  from  the 
pump  will  clear  the  canal. 

Difficulties  of  Esophagoscopy. — The  beginner  may  find  the 
esophagoscope  seemingly  rigidly  fixed,  so  that  it  can  be  neither 
introduced  nor  withdraw^n.  This  usually  results  from  a  wedging 
of  the  tube  in  the  dental  angle,  and  is  overcome  by  a  wider  opening 
of  the  jaws,  or  perhaps  by  easing  up  of  the  bite  block,  but  most 
often  by  correcting  the  position  of  the  patient's  head.  If  the 
beginner  cannot  start  the  tube  into  the  pyriform  sinus  in  an  adult, 
it  is  a  good  plan  to  expose  the  arytenoid  eminence  with  the  laryngo- 
scope and  then  to  insert  the  7  mm.  esophagoscope  into  the  right 
pyriform  sinus  by  direct  vision.  Passing  the  cricopharyngeal 
and  hiatal  spasmodically  contracted  narrowings  will  prove  the 
most  trying  part  of  esophagoscopy;  but  with  the  head  properly 
held,  and  the  tube  properly  placed  and  directed,  patient  waiting 
for  relaxation  of  the  spasm  with  gentle  continuous  pressure  will 
usually  expose  the  lumen  ahead.  In  his  first  few  esophagoscopies 
the  novice  had  best  use  general  anesthesia  to  avoid  these  diffi- 
culties and  to  accustom  himself  to  the  esophageal  image.  In  the 
first  favorable  subject — an  emaciated  individual  with  no  teeth — 
esophagoscopy  without  anesthesia  should  be  tried. 

In  cases  of  kyphosis  it  is  a  mistake  to  try  to  straighten  the 
spine.  The  head  should  be  held  correspondingly  higher  at  the 
beginning,  and  should  be  very  slowly  and  cautiously  lowered. 

Once  inserted,  the  esophagoscope  should  not  be  removed  until 
the  completion  of  the  procedure,  unless  respiratory  arrest  demands 
it.  Occasionally  in  stenotic  conditions  the  light  may  become 
covered  by  the  upweUing  of  a  flood  of  fluid,  and  it  will  be  thought 
the  light  has  gone  out.  As  soon  as  the  fluid  has  been  aspirated 
the  light  will  be  found  burning  as  brightly  as  before.     If  a  lamp 


114  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

should  fail  it  is  unnecessary  to  remove  the  tube,  as  the  light  carrier 
and  light  can  be  withdrawn  and  quickly  adjusted.  A  complete 
instrument  equipment  with  proper  selection  of  instruments  for 
the  particular  case  are  necessary  for  smooth  working. 

Ballooning  Esophagoscopy. — By  inserting  the  window  plug 
shown  in  Fig.  6  the  esophagus  may  be  inflated  and  studied  in  the 
distended  state.  The  folds  are  thus  smoothed  out  and  constric- 
tions rendered  more  marked.  Ether  anesthesia  is  advocated  by 
Mosher.  The  danger  of  respiratory  arrest  from  pressure,  should 
the  patient  be  dyspneic,  is  always  present  unless  the  anesthetic 
be  given  by  the  intratracheal  method.  If  necessary  to  use 
forceps  the  window  cap  is  removed.  If  the  perforated  rubber 
diaphragm  cap  be  substituted  the  esophagus  can  be  reballooned, 
but  work  is  no  longer  ocularly  guided.  The  fluoroscope  may  be 
used  but  is  so  misleading  as  to  render  perforation  and  false  passage 
likely. 

Specular  Esophagoscopy. — Inspection  of  the  hypopharynx  and 
upper  esophagus  is  readily  made  with  the  esophageal  speculum 
shown  in  Fig.  4.  High  lesions  and  foreign  bodies  lodged  behind 
the  larynx  are  thus  discovered  with  ease,  and  such  a  condition  as  a 
retropharyngeal  abscess  which  has  burrowed  downward  is  much 
less  apt  to  be  overlooked  than  with  the  esophagoscope.  High 
strictures  of  the  esophagus  may  be  exposed  and  treated  by  direct 
visual  bouginage  until  the  lumen  is  sufficiently  dilated  to  allow  the 
passage  of  the  esophagoscope  for  bouginage  of  the  deeper  strictures. 

Technic  of  Specular  Esophagoscopy. — Recumbent  patient. 
Boyce  position.  The  larynx  is  to  be  exposed  as  in  direct  laryngos- 
copy, the  right  pyriform  sinus  identified,  the  tip  of  the  speculum 
inserted  therein,  and  gently  insinuated  to  the  cricopharyngeal 
constriction.  Too  great  extension  of  the  head  is  to  be  avoided — 
even  slight  flexion  at  the  occipito-atloid  joint  may  be  found  useful 
at  times.     Moderate  anterior  or  upward  traction  pulls  the  cricoid 


INTRODUCTIOX  OF  THE  ESOPHAGOSCOPE  II5 

away  from  the  posterior  pharyngeal  wall  and  the  lumen  of  the 
esophagus  opens  above  a  crescentic  fold  (the  cricopharyngeus). 
The  speculum  readily  slides  over  this  fold  and  enters  the  cervical 
esophagus.  In  searching  for  foreign  bodies  in  the  esophagus  the 
speculum  has  the  disadvantage  of  limited  length,  so  that  should 
the  foreign  body  move  downward  it  could  not  be  followed. 

Complications  Following  Esophagoscopy. — These  are  to  be 
avoided  in  large  measure  by  the  exercise  of  gentleness,  care,  and 
skill  that  are  acquired  by  practice.  If  the  instructions  herein 
given  are  followed,  esophagoscopy  is  absolutely  without  mortality 
apart  from  the  conditions  for  which  it  is  done. 

Injury  to  the  crico-arytenoid  joint  may  simulate  recurrent 
paralysis.  Posticus  paralysis  may  occur  from  recurrent  or  vagal 
pressure  by  a  misdirected  esophagoscope.  These  conditions 
usually  recover  but  may  persist.  Perforation  of  the  esophageal 
wall  may  cause  death  from  septic  mediastinitis.  The  pleura  may 
be  entered, — pyopneumothorax  will  result  and  demand  immediate 
thoracotomy  and  gastrostomy.  Aneurysm  of  the  aorta  may  be 
ruptured.  Patients  with  tuberculosis,  decompensating  cardio- 
vascular lesions,  or  other  advanced  organic  disease,  may  have 
serious  complications  precipitated  by  esophagoscopy. 

Retrograde  Esophagoscopy. — The  first  step  is  to  get  rid  of  the 
gastric  secretions.  There  is  always  fluid  in  the  stomach,  and 
this  keeps  pouring  out  of  the  tube  in  a  steady  stream.  Fold  after 
fold  is  emptied  of  fluid.  Once  the  stomach  is  empty,  the  search 
begins  for  the  cardial  opening.  The  best  landmark  is  a  mark  with 
a  dermal  pencil  on  the  skin  at  a  point  corresponding  to  the  level  of 
the  hiatus  esophageus.  When  it  is  desired  to  do  a  retrograde 
esophagoscopy  and  the  gastrostomy  is  done  for  this  special 
purpose,  it  is  wise  to  have  it  very  high.  Once  the  cardia  is 
located  and  the  esophagus  entered,  the  remainder  of  the  work  is 
very  easy.     Bouginage  can  be  carried  out  from  below  the  same  as 


Il6  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

from  above  and  may  be  of  advantage  in  some  cases.  Strictural 
lumina  are  much  more  apt  to  be  concentric  as  approached  from 
below  because  there  has  been  no  distortion  by  pressure  dilatation 
due  to  stagnation  of  the  food  operating  through  a  long  period  of 
time.  At  retrograde  esophagoscopy  there  seems  to  be  no  abdom- 
inal esophagus  and  no  cardia.  The  esophagoscope  encounters 
only  the  diaphragmatic  pinchcock  which  seems  to  be  at  the  top  of 
the  stomach  like  the  puckering  string  at  the  top  of  a  bag. 

Retrograde  esophagoscopy  is  sometimes  useful  for  "string- 
ing" the  esophagus  in  cases  in  which  the  patient  is  unable  to 
swallow  a  string  because  he  is  too  young  or  because  of  an  epithelial 
sealing  over  of  the  upper  entrance  of  the  stricture.  In  such  cases 
the  smallest  size  of  the  author's  filiform  bougies  (Fig.  40)  is 
inserted  through  the  retrograde  esophagoscope  (Fig.  43)  and 
insinuated  upward  through  the  stricture.  When  the  tip  reaches 
the  pharynx  coughing,  choking  and  gagging  are  noticed.  The 
filiform  end  is  brought  out  the  mouth  sufficiently  far  to  attach 
a  silk  braided  cord  which  is  then  pulled  down  and  out  of  the 
gastrostomic  opening.  The  braided  silk  "string"  must  be  long 
enough  so  that  the  oral  and  the  abdominal  ends  can  be  tied 
together  to  make  it  "endless;"  but  before  doing  so  the  oral  end 
should  be  drawn  through  nose  where  it  will  be  less  annoying 
than  in  the  mouth.  The  purpose  of  the  "string"  is  to  pull  up 
the  retrograde  bougies  (Fig.  35). 


CHAPTER  XI 

ACQUIRING  SKILL 

Endoscopic  ability  cannot  be  bought  with  the  instruments. 
As  with  all  mechanical  procedures,  facility  can  be  obtained  only 
by  educating  the  eye  and  the  fingers  in  repeated  exercise  of  a 
particular  series  of  maneuvers.  As  with  learning  to  play  a  musical 
instrument,  a  fundamental  knowledge  of  technic,  positions,  and 
landmarks  is  necessary,  after  which  only  continued  manual 
practice  makes  for  proficiency.  For  instance,  efficient  use  of 
forceps  requires  that  they  be  so  familiar  to  the  grasp  that  their 
use  is  automatic.  Endoscopy  is  a  purely  manual  procedure, 
hence  to  know  how  is  not  enough:  manual  practice  is  necessary. 
Even  in  the  handling  of  the  electrical  equipment,  practice  in 
quickly  locating  trouble  is  as  essential  as  theoretic  knowledge. 
There  is  no  mystery  about  electric  lighting.  No  source  of 
illumination  other  than  electricity  is  possible  for  endoscopy. 
Therefore  a  small  amount  of  electrical  knowledge,  rendered  practical 
by  practice,  is  essential  to  maintain  the  simple  lighting  system 
in  working  order.  It  is  an  insult  to  the  intelligence  of  the  physi- 
cian to  say  that  he  cannot  master  a  simple  problem  of  electric 
testing  involving  the  locating  of  one  or  more  of  five  possibilities. 
It  is  simply  a  matter  of  memorizing  five  tests.  It  is  repeated  for 
emphasis  that  a  commercial  current  reduced  by  means  of  a  rheo- 
stat should  never  be  used  as  a  source  of  current  for  endoscopy  with 
any  kind  of  instrument,  because  of  the  danger  to  the  patient  of  a 
possible  "grounding"  of  the  circuit  during  the  extensive  moist 
contact  of  a  metallic  endoscopic  tube  in  the  mediastinum.  The 
battery  shown  in  Fig.  8  should  be  used.     The  most  frequent  cause 

of  trouble  is  the  mistake  of  over-illuminating  the  lamps.     The 

117 


Il8  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

lamp  should  not  be  over-illuminated  to  the  dazzling  whiteness  usually 
used  in  flash  lights.  Excessive  illumination  alters  the  proper 
perception  of  the  coloring  of  the  mucosa,  besides  shortening  the  life 
of  the  lamps.  The  proper  degree  of  brightness  is  obtained  when, 
as  the  current  is  increased,  the  first  change  from  yellow  to  white 
light  is  obtained.  Never  turn  up  the  rheostat  without  watching 
the  lamp. 

Testing  for  Electric  Dejects. — These  tests  should  be  made 
beforehand;  not  when  about  to  commence  introduction. 

If  the  first  lamp  lights  up  properly,  use  it  with  its  light-carrier 
to  test  out  the  other  cords. 

If  the  lamp  lights  up,  but  flickers,  locate  the  trouble  before 
attempting  to  do  an  endoscopy.  If  shaking  the  carrier  cord- 
terminal  produces  flickering  there  may  be  a  film  of  corrosion  on 
the  central  contact  of  the  light  carrier  that  goes  into  the  carrier 
cord-terminal. 

If  the  lamp  fails  to  show  a  light,  the  trouble  may  be  in  one  of 
five  places  which  should  be  tested  for  in  the  following  order  and 
manner. 

1.  The  lamp  may  not  be  firmly  screwed  into  the  light-carrier. 
Withdraw  the  light-carrier  and  try  screwing  it  in,  though  not  too 
strongly,  lest  the  central  wire  terminal  in  the  lamp  be  bent  over. 

2.  The  light-carrier  may  be  defective. 

3.  The  cord  may  be  defective  or  its  terminals  not  tight  in  the 
binding  posts.  If  screwing  down  the  thumb  nuts  does  not  pro- 
duce a  light,  test  the  light-carrier  with  lamp  on  the  other  cords. 
Reserve  cords  in  each  pair  of  binding  posts  are  for  use  instead  of 
the  defective  cords.  The  two  sets  of  cords  from  one  pair  of 
binding  posts  should  not  be  used  simultaneously. 

4.  The  lamp  may  be  defective.     Try  another  lamp. 

5.  The  battery  may  be  defective.  Take  a  cord  and  light- 
carrier  with  lamp  that  lights  up,  detaching  the  cord-terminals  at 


ACQUIRING    SKILL  II9 

the  binding  posts,  and  attach  the  terminals  to  the  binding  posts 
of  the  battery  to  be  tested. 

Efficient  use  of  forceps  requires  previous  practice  in  handling  of 
the  forceps  until  it  has  become  as  natural  and  free  from  thought 
as  the  use  of  knife  and  fork.  Indeed  the  coordinate  use  of  the 
bronchoscopic  tube-mouth  and  the  forceps  very  much  resembles 
the  use  of  knife  and  fork.  Yet  only  too  often  a  practitioner  will 
telegraph  for  a  bronchoscope  and  forceps,  and  without  any  practice 
start  in  to  remove  an  entangled  or  impacted  foreign  body  from 
the  tiny  bronchi  of  a  child.  Failure  and  mortality  are  almost 
inevitable.  A  few  hundred  hours  spent  in  working  out,  on  a  bit 
of  rubber  tubing,  the  various  mechanical  problems  given  in  the 
section  on  that  subject  will  save  lives  and  render  easily  successful 
many  removals  that  would  otherwise  be  impossible. 

It  is  often  difficult  for  the  beginner  to  judge  the  distance  the 
forceps  have  been  inserted  into  the  tube.  This  difficulty  is  readily 
solved  if  upon  inserting  the  forceps  slowly  into  the  tube,  he 
observes  that  as  the  blades  pass  the  light  they  become  brightly 
illuminated.  By  this  light  reflex  it  is  known,  therefore,  that  the 
forceps  blades  are  at  the  tube-mouth,  and  distance  from  this 
point  can  be  readily  gauged.  Excellent  practice  may  be  had  by 
picking  up  through  the  bronchoscope  or  esophagoscope  black 
threads  from  a  white  background,  then  white  threads  from  a  black 
background,  and  finally  white  threads  on  a  white  background  and 
black  threads  on  a  black  background.  This  should  be  done  first 
with  the  9  mm.  bronchoscope.  It  is  to  be  remembered  that  the 
majority  of  foreign  body  accidents  occur  in  children,  with  whom 
small  tubes  must  be  used;  therefore,  practice  work,  after  say  the 
first  100  hours,  should  be  done  with  the  5  mm.  bronchoscope  and 
corresponding  forceps  rather  than  adult  size  tubes,  so  that  the 
operator  will  be  accustomed  to  work  through  a  small  calibre  tube 
when  the  actual  case  presents  itself. 


I20  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

Cadaver  Practice. — The  fundamental  principles  of  peroral 
endoscopy  are  best  taught  on  the  cadaver.  It  is  necessary  that  a 
specially  prepared  subject  be  had,  in  order  to  obtain  the  required 
degree  of  flexibility.  Injecting  fluid  of  the  following  formula 
worked  out  by  Prof.  J.  Parsons  Schaeffer  for  the  Bronchoscopic 
Clinic  courses,  has  proved  very  satisfactory: 

Sodium  carbonate i  J^  lbs. 

White  arsenic 2}^  lbs. 

Potassium  nitrate 3      lbs. 

Water 5      gal. 

Boil  until  arsenic  is  dissolved.     When  cold  add: 

Carbolic  acid 1500  c.c. 

Glycerin 1 250  c.c. 

Alcohol  (95%) 1250  c.c. 

For  each  body  use  about  3  gal.  of  fluid. 

The  method  of  introduction  of  the  endoscopic  tube,  and  its 
various  positions  can  be  demonstrated  and  repeatedly  practiced 
on  the  cadaver  until  a  perfected  technic  is  developed  in  both  the 
operator  and  assistant  who  holds  the  head,  and  the  one  who 
passes  the  instruments  to  the  operator.  In  no  other  manner  can 
the  landmarks  and  endoscopic  anatomy  be  studied  so  thoroughly 
and  practically,  and  in  no  other  way  can  the  pupil  be  taught  to 
avoid  killing  his  patient.  The  danger-points  in  esophagoscopy 
are  not  demonstrable  on  the  living  without  actually  incurring 
mortality.  Laryngeal  growths  may  be  simulated,  foreign  body 
problems  created  and  their  mechanical  difficulties  solved  and  prac- 
tice work  with  the  forceps  and  tube  perfected. 

Practice  on  the  Rubber-tube  Manikin. — This  must  be  carried 
out  in  two  ways. 

I.  General  practice  with  all  sorts  of  objects  for  the  education 
of  the  eye  and  the  fingers. 


ACQUIRING    SKILL  121 

2.  Before  undertaking  a  foreign  body  case,  practice  should  be 
had  with  a  duplicate  of  the  foreign  body. 

It  is  not  possible  to  have  a  cadaver  for  daily  practice,  but 
fortunately  the  eye  and  fingers  may  be  trained  quite  as  effectually 
by  simulating  foreign  body  conditions  in  a  small  red  rubber  tube 
and  solving  these  mechanical  problems  with  the  bronchoscope 
and  forceps.  The  tubing  may  be  placed  on  the  desk  and  held  by 
a  small  vise  (Fig.  72)  so  that  at  odd  moments  during  the  day  or 


Fig.  72. — A  simple  manikin.  The  weight  of  the  small  vise  serves  to  steady  the 
rubber  tubing.  By  the  use  of  tubing  of  the  size  of  the  invaded  bronchus  and  a 
duplicate  of  the  foreign  body,  any  mechanical  problem  can  be  simulated  for  solution 
or  for  practice,  study  of  all  possible  presentations,  etc. 

evening  the  fascinating  work  may  be  picked  up  and  put  aside 
without  loss  of  time.  Complicated  rubber  manikins  are  of  no 
value  in  the  practice  of  introduction,  and  foreign  body  problems 
can  be  equally  well  studied  in  a  piece  of  rubber  tubing  about  10 
inches  long.  No  endoscopist  has  enough  practice  on  the  living 
subject,  because  the  cases  are  too  infrequent  and  furthermore  the 
tube  is  inserted  for  too  short  a  space  of  time.  Practice  on  the 
rubber  tube  trains  the  eye  to  recognize  objects  and  to  gauge  dis- 
tance; it  develops  the  tactile  sense  so  that  a  knowledge,  of  the 
character  of  the  object  grasped  or  the  nature  of  the  tissues  palpated 
may  be  acquired.     Before  attempting  the  removal  of  a  particular 


122  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

foreign  body  from  a  living  patient,  the  anticipated  problem  should 
be  simulated  with  a  duplicate  of  the  foreign  body  in  a  rubber  tube. 
In  this  way  the  endoscopist  may  precede  each  case  with  a  practical 
experience  equivalent  to  any  number  of  cases  of  precisely  the  same 
kind  of  foreign  body.  If  the  object  cannot  be  removed  from  the 
rubber  tube  without  violence,  it  is  obvious  that  no  attempt  should 
be  made  on  the  patient  until  further  practice  has  shown  a  definite 
method  of  harmless  removal.  During  practice  work  the  value 
of  the  beveled  lip  of  the  bronchoscope  and  esophagoscope  in 
solving  mechanical  problems  will  be  evidenced.  With  it  alone,  a 
foreign  body  may  be  turned  into  favorable  positions  for  extraction, 
and  folds  can  always  be  held  out  of  the  way.  Sufficient  combined 
practice  with  the  bronchoscope  and  the  forceps  enable  the 
endoscopist  easily  to  do  things  that  at  first  seem  impossible.  It 
is  to  be  remembered  that  lateral  motion  of  the  long  slender  tube- 
forceps  cannot  be  controlled  accurately  by  the  handle,  this  is 
obtained  by  a  change  in  position  of  the  endoscopic  tube,  the  object 
being  so  centered  that  it  is  grasped  without  side  motion  of  the 
forceps.  When  necessary,  the  distal  end  of  the  forceps  may  be 
pushed  laterally  by  the  manipulation  of  the  bronchoscope. 
Practice  on  the  Dog. — Having  mastered  the  technic  of  introduc- 
tion on  the  cadaver  and  trained  the  eye  and  fingers  by  practice 
work  on  the  rubber  tube,  experience  should  be  had  in  the  living 
lower  air  and  food  passages  with  their  pulsatory,  respiratory, 
bechic  and  deglutitory  movements,  and  ever-present  secretions. 
It  is  not  only  inhuman  but  impossible  to  obtain  this  experience  on 
children.  Fortunately  the  dog  offers  a  most  ready  subject  and 
need  in  no  way  be  harmed  nor  pained  by  this  invaluable  and  life- 
saving  practice.  A  small  dog  the  size  of  a  terrier  (say  6  to  lo 
pounds  in  weight)  should  be  chosen  and  anesthetized  by  the  hypo- 
dermic injection  of  morphin  sulphate  in  dosage  of  approximately 
one-sixth  of  a  grain  per  pound  of  body  weight,  given  about  45 


ACQUIRING   SKILL 


123 


minutes  before  the  time  of  practice.  Dogs  stand  large  doses 
of  morphin  without  apparent  ill  effect,  so  that  repeated  injection 
may  be  given  in  smaller  dosage  until  the  desired  degree  of  relaxation 
results.  The  first  effect  is  vomiting  which  gives  an  empty  stom- 
ach for  esophagoscopy  and  gastroscopy.  Vomiting  is  soon  fol- 
lowed by  relaxation  and  stupor.     The  dog  is  normal  and  hungry 


Fig  73. — Author's  mouth  gag  for  use  on  the  dog.  The  thumb-nut  serves  to 
prevent  an  uncomfortable  degree  of  expansion  of  the  gag.  A  bandage  may  be 
wound  around  the  dog's  jaws  to  prevent  undue  spread  of  the  jaws. 


in  a  few  hours.  Dosage  must  be  governed  in  the  dog  as  in  the 
human  being  by  the  suspectibility  to  the  drug  and  by  the  tempera- 
ment of  the  animal.  Other  forms  of  anesthesia  have  been  tried 
in  my  teaching,  and  none  has  proven  so  safe  and  satisfactory. 
Phonation  may  be  prevented  during  esophagoscopy  by  preventing 
approximation  of  the  cords,  through  inserting  a  silk-woven  cathe- 
ther  in  the  trachea.  The  larynx  and  trachea  may  be  painted  with 
cocain  solution  if  it  is  found  necessary  for  bronchoscopy.  A  very 
comfortable  and  safe  mouth  gag  is  shown  in  Fig.   73.     Great 


124  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

gentleness  should  be  exercised,  and  no  force  should  be  used,  for 
none  is  required  in  endoscopic  work;  and  the  endoscopist  will  lose 
much  of  the  value  of  his  dog  practice  if  he  fails  to  regard  the  dog 
as  a  child.  He  should  remember  he  is  not  learning  how  to  do 
endoscopy  on  the  dog;  but  learning  on  the  dog  how  safely  to  do 
bronchoscopy  on  a  human  being.  The  degree  of  resistance  during 
introduction  can  be  gauged  and  the  color  of  the  mucosa  studied, 
while  that  interesting  phenomenon,  the  dilatation  and  lengthening 
of  the  bronchi  during  inspiration  and  their  contraction  and 
shortening  during  expiration,  is  readily  observed  and  always  forms 
subject  for  thought  in  its  possible  connection  with  pathological 
conditions.  Foreign  body  problems  are  now  to  be  solved  under 
these  living  conditions,  and  it  is  my  feeling  that  no  one  should 
attempt  the  removal  of  a  foreign  body  from  the  bronchus  of  a 
child  until  he  has  removed  at  least  loo  foreign  bodies  from  the  dog 
without  harming  the  animal.  Dogs  have  the  faculty  of  easily 
ridding  their  air-passages  of  foreign  objects,  so  that  one  need  not 
be  alarmed  if  a  foreign  body  is  lost  during  practice  removal.  It  is 
to  be  remembered  that  dogs  swallow  very  large  objects  with 
apparent  ease.  The  dog's  esophagus  is  relatively  much  larger 
than  that  of  human  beings.  Therefore  a  small  dog  (of  six  to  eight 
pounds'  weight)  must  be  used  for  esophagoscopic  practice,  if 
practice  is  to  be  had  with  objects  of  the  size  usually  encountered 
in  human  beings.  The  bronchi  of  a  dog  of  this  weight  will  be 
about  the  size  of  those  of  a  child. 

Endoscopy  on  the  Human  Being. — Dog  work  offers  but  little 
practice  in  laryngoscopy.  Because  of  the  slight  angle  at  which  the 
dog's  head  joins  his  spine,  the  larynx  is  in  a  direct  line  with  the 
open  mouth;  hence  little  displacement  of  the  anterior  cervical 
tissues  is  necessary.  Moreover  the  interior  of  the  larynx  of  the 
dog  is  quite  different  from  that  of  the  human  larynx.  The 
technic  of  laryngoscopy  in  the  human  subject  is  best  perfected  by 


ACQUIRING    SKILL  1 25 

a  routine  direct  examination  of  the  larynx  of  anesthetized  patients 
after  such  an  operation  as,  for  instance,  tonsillectomy,  to  see  that 
the  larynx  and  laryngopharynx  are  free  of  clots.  To  perform  a 
bronchoscopy  or  esophagoscopy  under  these  conditions  would  be 
reprehensible;  but  direct  laryngoscopy  for  the  seeking  and  removal 
of  clots  serves  a  useful  purpose  as  a  preventative  of  pulmonary 
abscess  and  similar  complications.*  Diagnosis  of  laryngeal  condi- 
tions in  young  children  is  possible  only  by  direct  laryngoscopy  and 
is  neglected  in  almost  all  of  the  cases.  No  anesthesia,  general  or 
local,  is  required.  Much  clinical  material  is  neglected.  All  cases 
of  dyspnea  or  dysphagia  should  be  studied  endoscopically  if  the 
cause  of  the  condition  cannot  be  definitely  found  and  treated  by 
other  means.  Invaluable  practice  in  esophagoscopy  is  found  in 
the  treatment  of  strictures  of  the  esophagus  by  weekly  or  bi- 
weekly esophagoscopic  bouginage. 

In  acquiring  skill  as  an  endoscopist  the  following  paraphrased 
aphorisms  aflford  food  for  thought. 

APHORISMS 

Educate  your  eye  and  your  lingers. 

Be  sure  you  are  right,  but  not  too  sure. 

Follow  your  judgment,  never  your  impulse. 

Cry  over  spilled  milk  enough  to  memorize  how  you  spilled  it. 

Let  your  mistakes  worry  you  enough  to  prevent  repetition. 

Let  your  left  hand  know  what  your  right  hand  does  and  how 
to  do  it. 

Nature  helps,  but  she  is  no  more  interested  in  the  survival  of 
your  patient  than  in  the  survival  of  the  attacking  pathogenic 
bacteria. 

*  Dr.  William  Frederick  Moore,  of  the  Bronchoscopic  Clinic,  has  recently 
collected  statistics  of  202  cases  of  post-tonsillectomic  pulmonary  abscess  that  point 
strongly  to  aspiration  of  infected  clots  and  other  infective  materials  as  the  most 
frequent  etiologic  mechanism  (Moore,  W.  F.,  Pulmonary  Abscess.  Journ.  Am.  Med. 
Assn.,  April  29,  1922,  Vol.  78,  pp.  1279-1281). 


CHAPTER  XII 
FOREIGN  BODIES  IN  THE  AIR  AND  FOOD  PASSAGES 

The  air  and  food  passages  may  be  invaded  by  any  foreign 
substance  of  solid,  liquid  or  gaseous  nature,  from  the  animal^ 
vegetable,  or  mineral  kingdoms.  Its  origin  may  be  from  within 
the  body  (blood,  pus,  secretion,  broncholiths,  sequestra,  worms); 
introduced  from  without  by  way  of  the  natural  passages  (aspirated 
or  swallowed  objects);  or  it  may  enter  by  penetration  (bullet^ 
dart,  drainage  tube  from  the  neck) . 

Prophylaxis. — If  one  put  into  his  mouth  nothing  but  food, 

foreign  body  accidents  would  be  rare.     The  habit  of  holding  tacks, 

pins  and  whatnot  in  the  mouth  is  quite  universal  and  deplorable. 

Children  are  prone  to  follow  the  bad  example  of   their  elders. 

No  small  objects  such  as  safety  pins,  buttons,  and  coins  should  be 

left  within  a  baby's  reach;  children  should  be  watched  and  taught 

not  to  place  things  in  their  mouths.     Mothers  should  be  specially 

cautioned  not  to  give  nuts  or  nut  candy  of  any  kind  to  a  child 

whose  powers  of  mastication  are  imperfect,  because  the  molar 

teeth  are  not  erupted.     It  might  be  made  a  dictum  that:  "No 

child  under  3  years  of  age  should  be  allowed  to  eat  nuts,  unless 

ground  finely  as  in  peanut  butter."     Digital  efforts  at  removal  of 

foreign  bodies  frequently  force  the  object  downward,  or  may  hook 

it  forward  into  the  larynx,  whereas  if  not  meddled  with  digitally 

the  intruder  might  be  spat  out.     Before  general  anesthesia  the 

mouth  should  be  searched  for  loose  teeth,  removable  dentures,  etc., 

and   all  unconscious  individuals   should   be  likewise  examined. 

When  working  in  the  mouth  precautions  should  be  taken  against 

the    possible    inhalation    or    swallowing    of    loose    objects    or 

instruments. 

126 


FOREIGN   BODIES    IN    THE    AIR    AND    FOOD    PASSAGES  1 27 

Objects  that  have  lodged  in  the  esophagus,  larynx,  trachea,  or 
bronchi  should  be  endoscopically  removed. 

Foreign  Bodies  in  the  Insane.— ¥  ox  eign  bodies  may  be  intro- 
duced voluntarily  and  in  great  numbers  by  the  insane.  Hysterical 
individuals  may  assert  the  presence  of  a  foreign  body,  or  may  even 
volitionally  swallow  or  aspirate  objects.  It  is  a  mistake  to  do  a 
bronchoscopy  in  order  to  cure  by  suggestion  the  delusion  of 
foreign  body  presence.     Such  "cures"  are  ephemeral. 

Foreign  Bodies  in  the  Stomach. — Gastroscopy  is  indicated  in 
cases  of  a  foreign  body  that  refuses  to  pass  after  a  month  or  two. 
Foreign  bodies  in  very  large  numbers  in  the  stomach,  as  in  the 
insane,  may  be  removed  by  gastrostomy. 

The  symptomatology  of  foreign  bodies  may  be  epitomized  as 
given  below;  but  it  must  be  kept  in  mind,  that  certain  symptoms 
may  not  be  manifest  immediately  after  intrusion,  and  others  may 
persist  for  a  time  after  the  passage,  removal,  or  expulsion  of  a 
foreign  body. 

ESOPHAGEAL  FOREIGN  BODY  SYMPTOMS 

1.  There  are  no  absolutely  diagnostic  symptoms. 

2.  Dysphagia,  however,  is  the  most  constant  complaint, 
varying  with  the  size  of  the  foreign  body,  and  the  degree  of  inflam- 
matory or  spasmodic  reaction  produced. 

3.  Pain  may  be  caused  by  penetration  of  a  sharp  foreign  body, 
by  inflammation  secondary  thereto,  by  impaction  of  a  large  object, 
or  by  spasmodic  closure  of  the  hiatus  esophageus. 

4.  The  subjective  sensation  of  foreign  body  is  usually  present, 
but  cannot  be  relied  upon  as  assuring  the  presence  of  a  foreign 
body  for  this  sensation  often  remains  for  a  time  after  the  passage 
onward  of  the  intruder. 

5.  All  of  these  symptoms  may  exist,  often  in  the  most  intense 


128  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

degree,  as  the  result  of  previous  violent  attempts  at  removal; 
and  the  foreign  body  may  or  may  not  be  present. 

SYMPTOMS  OF  LARYNGEAL  FOREIGN  BODY 

1.  Initial  laryngeal  spasm  followed  by  wheezing  respiration, 
■croupy  cough,  and  varying  degrees  of  impairment  of  phonation. 

2.  Pain  may  be  a  symptom.  If  so,  it  is  usually  located  in 
the  laryngeal  region,  though  in  some  cases  it  is  referred  to  the  ears. 

3.  The  larynx  may  tolerate  a  thin,  flat,  foreign  body  for  a 
relatively  long  period  of  time,  a  month  or  more;  but  the  develop- 
ment of  increasing  dyspnea  renders  early  removal  imperative  in 
the  majority  of  cases. 

SYMPTOMS  OF  TRACHEAL  AND  BRONCHIAL  FOREIGN  BODY 

1.  Tracheal  foreign  bodies  are  usually  movable  and  their 
movements  can  usually  be  felt  by  the  patient. 

2.  Cough  is  usually  present  at  once,  may  disappear  for  a 
time  and  recur,  or  may  be  continuous,  and  may  be  so  violent  as  to 
induce  vomiting.  In  recent  cases  fixed  foreign  bodies  cause  little 
cough;  shifting  foreign  bodies  cause  violent  coughing. 

3.  Sudden  shutting  off  of  the  expiratory  blast  and  the  phona- 
tion during  paroxysmal  cough  is  almost  pathognomonic  of  a 
movable  tracheal  foreign  body. 

4.  Dyspnea  is  usually  present  in  tracheal  foreign  bodies,  and 
is  due  to  the  bulk  of  the  foreign  body  plus  the  subglottic  swelling 
caused  by  the  traumatism  of  the  shiftings  of  the  intruder. 

5.  Dyspnea  is  usually  absent  in  bronchial  foreign  bodies. 

6.  The  respiratory  rate  is  increased  only  if  a  considerable 
portion  of  lung  is  out  of  function,  by  the  obstruction  of  a  main 
bronchus,  or  if  inflammatory  sequelae  are  extensive. 

7.  The    asthmatoid   wheeze   is    usually   present   in    tracheal 


FOREIGN   BODIES    IN    THE    AIR    AND    FOOD    PASSAGES  1 29 

foreign  bodies,  and  is  often  louder  and  of  lower  pitch  than  the 
asthmatoid  wheeze  of  bronchial  foreign  bodies.  It  is  heard  at 
the  open  mouth,  not  at  the  chest  wall;  and  prolonged  expiration 
as  though  to  rid  the  lungs  of  all  residual  air,  may  be  necessary  to 
elicit  it. 

8.  Pain  is  not  a  common  symptom,  but  may  occur  and  be 
accurately  localized  by  the  patient,  in  case  of  either  tracheal  or 
bronchial  foreign  body. 

EARLY  SYMPTOMS  OF  IRRITATING  FOREIGN  BODY  SUCH  AS  A  PEANUT 
KERNEL  IN  THE  BRONCHUS 

1.  Initial  laryngeal  spasm  is  almost  invariably  present  with 
foreign  bodies  of  organic  nature,  such  as  nut  kernels,  peas,  beans, 
maize,  etc. 

2.  A  diffuse  purulent  laryngo-tracheo-bronchitis  develops 
within  24  hours  in  children  under  2  years. 

3.  Fever,  toxemia,  cyanosis,  dyspnea  and  paroxysmal  cough 
are  promptly  shown. 

4.  The  child  is  unable  to  cough  up  the  thick  mucilaginous  pus 
through  the  swollen  larynx  and  may  "drown  in  its  own  secretions" 
unless  the  offender  be  removed. 

5.  "Drowned  lung,"  that  is  to  say  natural  passages  filled  with 
pus  and  secretions,  rapidly  forms. 

6.  Pulmonary  abscess  develops  sooner  than  in  case  of  mineral 
foreign  bodies. 

7.  The  older  the  child  the  less  severe  the  reaction. 

SYMPTOMS  OF  PROLONGED  FOREIGN  BODY  SOJOURN  IN  THE 

BRONCHUS 

1.  The  time  of  inhalation  of  a  foreign  body  may  be  unknown 
or  forgotten. 

2.  Cough  and  purulent  expectoration  ultimately  result, 
although  there  may  be  a  delusive  protracted  symptomless  interval. 


130  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

3.  Periodic  attacks  of  fever,  with  chills  and  sweats,  and 
followed  by  increased  coughing  and  the  expulsion  of  a  large  amount 
of  purulent,  usually  more  or  less  foul  material,  are  so  nearly 
diagnostic  of  foreign  body  as  to  call  for  exclusion  of  this  probability 
with  the  utmost  care. 

4.  Emaciation,  clubbing  of  the  fingers  and  toes,  night  sweats, 
hemoptysis,  in  fact  all  of  the  symptoms  of  tuberculosis  are  in  most 
cases  simulated  with  exactitude,  even  to  the  gain  in  weight  by  an 
out-door  regime. 

5.  Tubercle  bacilli  have  never  been  found,  in  the  cases  at  the 
Bronchoscopic  Clinic,  associated  with  foreign  body  in  the 
bronchus.*  In  cases  of  prolonged  sojourn  this  has  been  the 
only  element  lacking  in  a  complete  clinical  picture  of  ad- 
vanced tuberculosis.  One  point  of  difference  was  the  almost 
invariably  rapid  recovery  after  removal  of  the  foreign  body. 
The  statement  in  all  of  the  text-books,  that  foreign  body 
is  followed  by  phthisis  pulmonalis  is  a  relic  of  the  days  when 
the  bacillary  origin  of  true  tuberculosis  was  unknown,  hence 
the  foreign-body  phthisis  pulmonalis,  or  pseudo  tuberculosis, 
was  confused  with  the  true  pulmonary  tuberculosis  of  bacillary 
origin. 

6.  The  subjective  sensation  of  pain  may  allow  the  patient 
accurately  to  localize  a  foreign  body. 

7.  Foreign  bodies  of  metallic  or  organic  nature  may  cause  their 
peculiar  taste  in  the  sputum. 

8.  Offensive  odored  sputum  should  always  suggest  bronchial 
foreign  body;  but  absence  of  sputum,  odorous  or  not,  should  not 
exclude  foreign  body. 

9.  Sudden  complete  obstruction  of  one  main  bronchus  does  not 
cause  noticeable  dyspnea  provided  its  fellow  is  functionating. 

*  The  exceptional  case  has  at  last  been  encountered.  A  boy  with  a  tack  in  the 
bronchus  was  found  to  have  pulmonary  tuberculosis. 


FOREIGN  BODIES   IN   THE   AIR   AND   FOOD   PASSAGES  13I 

10.  Complete  obstruction  of  a  bronchus  is  followed  by  rapid 
onset  of  symptoms. 

11.  The  physical  signs  usually  show  limitation  of  expansion 
on  the  affected  side,  impairment  of  percussion,  and  lessened  trans- 
mission or  absence  of  breath-sounds  distal  to  the  foreign  body. 

SYMPTOMS  OF  GASTRIC  FOREIGN  BODY 

Foreign  body  in  the  stomach  ordinarily  produces  no  symptoms. 
The  roentgenogram  and  the  fluoroscopic  study  with  an  opaque 
mixture  are  the  chief  means  of  diagnosis. 

DIAGNOSIS  OF  FOREIGN  BODY  IN  THE  AIR  OR  FOOD  PASSAGES 

The  questions  arising  are: 

1.  Is  a  foreign  body  present? 

2.  Where  is  it  located? 

3.  Is  a  peroral  endoscopic  procedure  indicated? 

4.  Are  there  any  contraindications  to  endoscopy? 

In  order  to  answer  these  questions  the  definite  routine  given 
below  is  followed  unvaryingly  in  the  Bronchoscopic  Clinic. 

1.  History. 

2.  Complete  physical  examination,  including  mirror  laryn- 
goscopy. 

3.  Roentgenogloic  study. 

4.  Endoscopy. 

The  history  should  note  the  date  of,  and  should  delve  into 
the  details  of  the  accident;  special  note  being  made  of  the  occur- 
rence of  laryngeal  spasm,  wheezing  respiration  heard  by  the 
patient  or  others  (asthmatoid  wheeze),  fever,  cough,  pain,  dyspnea, 
dysphagia,  odynphagia,  regurgitation,  etc.  The  amount,  char- 
acter and  odor  of  sputum  are  important.  Increasing  amounts  of 
purulent,  foul-odored,  sometimes  blood-tinged  sputum  strongly 
suggest  prolonged  bronchial  foreign  body  sojourn.     The  mode  of 


132  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

onset  of  the  persisting  symptoms,  whether  immediately  following 
the  supposed  accident  or  delayed  in  their  occurrence,  is  to  be  noted. 
Do  attacks  of  sudden  dyspnea  and  cyanosis  occur?  What  has 
been  the  previous  treatment  and  what  attempts  at  removal  have 
been  made?  The  nature  of  the  foreign  body  is  to  be  determined, 
and  if  possible  a  duplicate  thereof  obtained. 

General  physical  examination  should  be  complete  including 
inspection  of  the  eyes,  ears,  nose,  pharynx,  and  mirror  inspection 
of  the  naso-pharynx  and  larynx.  Special  attention  is  paid  to  the 
chest  for  the  localization  of  the  object.  In  order  to  discover  con- 
ditions rendering  endoscopy  unusually  hazardous,  all  parts  of  the 
body  are  to  be  examined.  Aneurysm  of  the  aorta,  excessive 
blood  pressure,  serious  cardiac  and  renal  conditions,  the  presence 
of  a  hernia  and  the  existence  of  central  nervous  disease,  as  tabes 
dorsalis,  should  be  at  least  known  before  attempting  any  endo- 
scopic procedure.  Dysphagia  might  result  from  the  pressure  of 
an  unknown  aneurysm,  the  symptoms  being  attributed  to  a  foreign 
body,  and  aortic  aneurysm  is  a  definite  contraindication  to  eso- 
phagoscopy  unless  there  be  foreign  body  present  also.  There  is 
no  absolute  contraindication  to  the  endoscopic  removal  of  a 
foreign  body,  though  many  conditions  may  render  it  wise  to  post- 
pone endoscopy.  Laryngeal  crises  of  tabes  might,  because  of  their 
sudden  onset,  be  thought  due  to  foreign  body. 

PHYSICAL  SIGNS  IN  ESOPHAGEAL  FOREIGN  BODY 

There  are  no  constant  physical  signs  associated  with  uncom- 
plicated impaction  of  a  foreign  body  in  the  esophagus.  Should 
perforation  of  the  cervical  esophagus  occur,  subcutaneous  emphy- 
sema, and  perhaps  cellulitis,  may  be  found;  while  a  perforation  of 
the  thoracic  region  causing  mediastinitis  is  manifested  by  toxemia, 
fever,  and  rapid  sinking.  Perforation  of  the  pleura,  with  the 
development  of  pyopneumothorax,  is  manifested  by  the  usual 


FOREIGN   BODIES    IX    THE    AIR    AND    FOOD    PASSAGES  1 33 

signs.  It  is  to  be  emphasized  that  bhnd  bouginage  has  no  place 
in  the  diagnosis  of  any  esophageal  condition.  The  roentgenologist 
will  give  the  information  we  desire  without  danger  to  the  patient, 
and  with  far  greater  accuracy. 

FOREIGN  BODIES  IN  THE  LARYNX 

Laryngeally  lodged  foreign  bodies  produce  a  wheezing  respira- 
tion, the  quality  of  which  is  peculiar  to  the  larynx  and  is  readily 
localized  to  this  organ.  If  swelling  or  the  size  of  the  foreign  body 
be  sufficient  to  produce  dyspnea,  inspiratory  indrawing  of  the 
suprasternal  notch,  supraclavicular  fossae,  costal  interspaces  and 
lower  sternum  will  be  present.  Cyanosis  is  only  an  accompani- 
ment of  suddenly  produced  dyspnea;  the  facies  will  therefore 
usually  be  anxious  and  pale,  unless  the  patient  is  seen  immediately 
after  the  aspiration  of  the  foreign  body.  If  labored  breathing  has 
been  prolonged,  and  exhaustion  threatened,  the  heart's  action  will 
be  irregular  and  weak.  The  foreign  body  can  be  seen  with  the 
mirror,  but  a  roentgenograph  must  nevertheless  be  made,  for 
the  object  may  be  of  another  nature  than  was  first  thought.  The 
roentgenograph  will  show  its  position,  and  from  this  knowledge 
the  plan  of  removal  can  be  formulated.  For  example,  a  straight 
pin  may  be  so  placed  in  the  larynx  that  only  a  portion  of  its  shaft 
will  be  visible,  the  roentgenogram  will  tell  where  the  head  and 
point  are  located,  and  which  of  these  will  be  the  more  readily 
disengaged.     (See  Chapter  on  Mechanical  Problems.) 

PHYSICAL  SIGNS  OF  TRACHEAL  FOREIGN  BODY 

If  fixed  in  the  trachea  the  only  objective  sign  of  foreign  body 
may  be  a  wheezing  respiration,  the  site  of  which  may  be  localized 
with  the  stethoscope,  by  the  intensity  of  the  sound.  Movable 
foreign  bodies  may  produce  a  palpatory  thrill,  and  the  rumble  and 
sudden  stop  can  be  heard  with  the  stethoscope  and  often  with  the 


134  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

naked  ear.  The  lungs  will  show  equal  aeration,  but  there  may  be 
marked  dyspnea  without  the  indrawing  of  the  fossae,  if  the  object 
be  of  large  size  and  located  below  the  manubrium. 

To  the  peculiar  sound  of  the  sudden  subglottic,  expiratory  or 
bechic  arrest  of  the  foreign  body  the  author  has  given  the  name 
"audible  slap;"  when  felt  by  the  thumb  on  the  trachea  he  calls 
it  the  "palpatory  thud."  These  signs  can  be  produced  by  no 
condition  other  than  the  arrest  of  some  substance  by  the  subglottic 
taper.     Once  heard  and  felt  they  are  unmistakable. 

PHYSICAL  SIGNS  OF  BRONCHIAL  FOREIGN  BODY 

In  most  cases  there  will  be  limitation  of  expansion  on  the 
invaded  side,  even  though  the  foreign  body  is  of  such  a  shape  as 
to  cause  no  bronchial  obstruction.  It  has  been  noted  frequently 
in  conjunction  with  the  presence  of  such  objects  as  a  common 
straight  pin  in  a  small  branch  bronchus.  This  peculiar  phenome- 
non was  first  noted  by  Thomas  McCrae  in  one  of  the  author's 
cases  and  has  since  been  abundantly  corroborated  by  McCrae  and 
others  as  one  of  the  most  constant  physical  signs. 

To  understand  the  peculiar  physical  findings  in  these  cases 
it  is  necessary  to  remember  that  the  bronchi  are  not  tubes  of  con- 
stant caliber;  there  occurs  a  dilatation  during  inspiration,  and  a 
contraction  of  the  lumen  during  expiration;  furthermore,  the 
lumen  may  be  narrowed  by  swollen  mucosa  if  the  foreigu  body  be 
of  an  irritant  nature.  The  signs  vary  with  the  degree  of  obstruc- 
tion of  the  bronchus,  and  with  the  consequent  degree  of  interfer- 
ence with  aeration  and  drainage  of  the  subjacent  portion  of  the 
lung.  We  have  three  definite  types  which  show  practically  con- 
stant signs  in  the  earlier  stages  of  foreign  body  invasion. 

1.  Complete  bronchial  occlusion. 

2.  Obstruction  complete  during  expiration,  but  allowing  the 


FOREIGN  BODIES   IN    THE   AIR   AND   FOOD    PASSAGES  135 

passage  of  air  during  the  bronchial  dilatation  incident  to  inspira- 
tion, constituting  an  expiratory  valve-like  obstruction. 

3.  Partial  bronchial  obstruction,  allowing  to-and-fro  passage 
of  air. 

1.  Complete  bronchial  obstruction  is  manifested  by  limitation 
of  expansion,  markedly  impaired  percussion  note,  particularly  at 
the  base,  absence  of  breath-sounds,  and  rales  on  the  invaded  side. 
An  atelectasis  here  exists;  the  air  imprisoned  in  the  lung  is  soon 
absorbed,  and  secretions  rapidly  accumulate.  On  the  free  side  a 
compensatory  emphysema  is  present. 

2.  Expiratory  Valve-like  Obstruction. — The  obstructed  side 
shows  marked  limitation  of  expansion.  Percussion  is  of  a  tympan- 
itic character.  The  duration  of  the  vibrations  may  be  shortened 
giving  a  muffled  tympany.  Various  grades  and  degrees  of  tym- 
pany may  be  noted.  Breath  sounds  are  markedly  diminished  or 
absent.  No  rales  are  heard  on  the  invaded  side,  although  rales 
of  all  types  may  be  present  on  the  free  side.  In  some  cases  it  is 
possible  to  hear  a  short  inspiratory  sound.  Vocal  resonance  and 
fremitus  are  but  little  altered.  The  heart  will  be  found  displaced 
somewhat  to  the  opposite  side.  These  signs  are  explained  by  the 
passage  of  some  air  past  the  foreign  body  during  inspiration  with 
its  trapping  during  expiration,  so  that  there  is  air  under  pressure 
constantly  maintained  in  the  obstructed  area.  This  type  of 
obstruction  is  most  frequently  observed  when  the  foreign  body  is 
of  an  organic  nature  such  as  nut  kernels,  beans,  corn,  seed,  etc. 
The  localized  swelling  about  the  irritating  foreign  body  completes 
the  expiratory  obstruction.  It  may  also  be  present  with  any 
foreign  body  whose  size  and  shape  are  such  as  to  occlude  the  lumen 
of  the  bronchus  during  its  contracted  expiratory  phase.  It  was 
present  in  cases  of  pebbles,  cylindrical  metallic  objects,  thick 
tough  balls  of  secretion  etcetera.  The  valvular  action  is  here 
produced  most  often  by  a  change  in  the  size  of  the  valve  seat  and 


136  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

not  by  a  movement  of  the  foreign  body  plug.  In  other  cases  I 
have  found  at  bronchoscopy,  a  regular  ball-valve  mechanism. 
Pneumothorax  is  the  only  pathologic  condition  associated  with 
signs  similar  to  those  of  expiratory,  valve-like  bronchial  obstruc- 
tion by  a  foreign  body. 

3.  Partial  bronchial  obstruction  by  an  object  such  as  a  nail 
allows  air  to  pass  to  and  fro  with  some  degree  of  retardation,  and 
impairs  the  drainage  of  the  subjacent  lung.  Limitation  of  expan- 
sion will  be  found  on  the  invaded  side.  The  area  below  the  foreign 
body  will  give  an  impaired  percussion  note.  Breath-sounds  are 
diminished  in  the  area  of  dulness,  and  vocal  resonance  and  fremi- 
tus are  impaired.  Rales  are  of  great  diagnostic  import;  the 
passage  of  air  past  the  foreign  body  is  accompanied  by  blowing, 
harsh  breathing,  and  snoring;  snapping  rales  are  heard  usually 
with  greatest  intensity  posteriorly  over  the  site  of  the  foreign 
body  (usually  about  the  scapular  angle). 

A  knowledge  of  the  topographical  lung  anatomy,  the  bronchial 
tree,  and  of  endoscopic  pathology*  should  enable  the  examiner 
of  the  chest  to  locate  very  accurately  a  bronchial  foreign  body  by 
physical  signs  alone,  for  all  the  significant  signs  occur  distal  to  the 
foreign  body  lodgment. 

The  asthmatoid  wheeze  has  been  found  by  the  author  a  valuable 
confirmatory  sign  of  bronchial  foreign  body.  It  is  a  wheezing 
heard  by  placing  the  observer's  ear  at  the  open  mouth  of  the 
patient  (not  at  the  chest  wall)  during  a  prolonged  forced  Expira- 
tion. Thomas  McCrae  elicits  this  sign  by  placing  the  stethoscope 
bell  at  the  patient's  open  mouth.  The  quality  of  the  sound  is 
dryer  than  that  heard  in  asthma  and  the  wheeze  is  clearest  after 
all  secretion  has  been  removed  by  coughing.     The  mechanism 

*  Jackson,  Chevalier.  Pathology  of  Foreign  Bodies  in  the  Air  and  Food  Pas- 
sages. Mutter  Lecture,  1918.  Surger> ,  Gynecology  and  Obstetrics,  March,  1919. 
Also,  b}'  the  same  author.  Mechanism  of  the  Physical  Signs  of  Foreign  Bodies  in  the 
Lungs.     Proceedings  of  the  College  of  Physicians,  Philadelphia,  1922. 


FOREIGN   BODIES    IN    THE    AIR    AND    FOOD    PASSAGES  137 

of  production  is,  probably,  the  passage  of  air  by  a  foreign  body 
which  narrows  the  lumen  of  a  large  bronchus.  As  the  foreign 
body  works  downward  the  wheeze  lessens.  The  wheeze  is  often 
so  loud  as  to  be  heard  at  some  distance  from  the  patient.  It  is 
of  greatest  value  in  the  diagnosis  of  non-roentgenopaque  foreign 
body  but  its  absence  in  no  way  negates  foreign  body.  Its  presence 
or  absence  should  be  recorded  in  every  case. 

Prolonged  bronchial  obstruction  by  foreign  body  is  followed 
by  bronchiectasis  and  lung  abscess  usually  in  a  lower  lobe.  The 
symptoms  may  with  exactitude  simulate  tuberculosis,  but  this 
disease  should  be  readily  excluded  by  the  basal,  unilateral  site  of 
the  lesion,  absence  of  tubercle  bacilli  in  the  sputum,  and  roent- 
genographic  study.  Chest  examination  in  the  foreign  body  cases 
reveals  limitation  of  expansion,  often  some  retraction,  fiat  per- 
cussion note,  and  greatly  diminished  or  absent  breath-sounds 
over  the  site  of  the  pulmonary  lesion.  Rales  vary  with  the  amount 
of  secretion  present.  These  physical  signs  suggest  empyema; 
and  rib  resection  had  been  done  before  admission  in  a  number  of 
cases  only  to  find  the  pleura  normal. 

ROENTGENRAY  STUDY  IN  FOREIGN  BODY  CASES 

Roentgenography . — All  cases  of  chest  disease  should  have  the 
benefit  of  a  roentgenologic  study  to  exclude  bronchial  foreign 
body  as  an  etiological  factor.  Negative  opinions  should  never 
be  based  upon  any  plates  except  the  best  that  the  wonderful 
modern  development  of  the  art  and  science  of  roentgenology  can 
produce.  In  doubtful  cases,  the  negative  opinion  should  not  be 
conclusive  until  a  roentgenologist  of  long  experience  in  chest  work, 
and  especially  in  foreign  body  cases,  has  been  called  in  consulta- 
tion. Even  then  there  will  be  an  occasional  case  calling  for 
diagnostic  bronchoscopy.  Antero-posterior  and  lateral  roentgeno- 
grams should  always  be  made.     In  an  antero-posterior  film  a  flat 


138  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

foreign  body  lying  in  the  lateral  body  plane  might  be  invisible  in 
the  shadow  of  the  spine,  heart,  and  great  vessels;  but  would  be 
revealed  in  the  lateral  view  because  of  the  greater  edgewise  density 
of  the  intruder  and  the  absence  of  other  confusing  shadows. 
Fluoroscopic  examination  will  often  discover  the  best  angle  from 
which  to  make  a  plate;  but  foreign  bodies  casting  a  very  faint 
shadow  on  a  plate  may  be  totally  invisible  on  the  fluoroscopic 
screen.  The  value  of  a  roentgenogram  after  the  removal  of  a 
foreign  body  cannot  be  too  strongly  emphasized.  It  is  evidence  of 
removal  and  will  exclude  the  presence  of  a  second  intruder  which 
might  have  been  overlooked  in  the  first  study. 

Fluoroscopic  study  of  the  swallowing  function  with  barium 
mixture,  or  a  barium-filled  capsule,  will  give  the  location  of  a  non- 
roentgenopaque  object  (such  as  bone,  meat,  etc.)  in  the  esophagus. 
If  a  flat  or  disc-shaped  object  located  in  the  cervical  region  is  seen 
to  be  lying  in  the  lateral  body  plane,  it  will  be  found  to  be  in  the 
esophagus,  for  it  assumed  that  position  by  passing  down  flatwise 
behind  the  larynx.  If,  however,  the  object  is  seen  to  be  in  the 
sagittal  plane  it  must  lie  in  the  trachea.  This  position  was  neces- 
sary for  it  to  pass  through  the  glottic  chink,  and  can  be  maintained 
because  of  the  yielding  of  the  posterior  membranous  wall  of  the 
trachea. 

THE  ROENTGENOGRAPHIC  SIGNS  OF  EXPIRATORY-VALVE-LIKE  BRON- 
CHIAL OBSTRUCTION 

The  roentgenray  signs  in  expiratory  valve-like  obstruction  of 
a  bronchus  are  those  of  an  acute  obstructive  emphysema  (Fig.  74), 
namely, 

1 .  Greater  transparency  on  the  obstructed  side  (Iglauer) . 

2.  Displacement  of  the  heart  to  the  free  side  (Iglauer). 

3.  Depression  and  flattening  of  the  dome  of  the  diaphragm 
•on  the  invaded  side  (Iglauer). 


FOREIGN  BODIES    IX    THE    AIR   AXD    FOOD    PASSAGES  1 39 

4.  Limitation  of  the  diaphragmatic  excursion  on  the  obstructed 
side  (Manges). 

It  is  very  important  to  note  that,  as  discovered  by  Manges, 
the  differential  emphysema  occurs  at  the  end  of  expiration  and  the 


Fig.  74 — Expiratory  valve  like  bronchial  obstruction  by  non-radiopaque 
foreign  body,  producing  an  acute  obstructive  emphysema.  Peanut  kernel  in  right 
main  bronchus.  Note  (a)  depression  of  right  diaphragm;  (b)  displacement  of  heart 
and  mediastinum  to  left;  (c)  greater  transparency  of  the  invaded  side.  Ray-plate 
made  by  Willis  F.  Manges. 

plate  must  be  exposed  at  that  time,  before  inspiration  starts. 
He  also  noted  that  at  fluoroscopy  the  heart  moved  laterally  toward 
the  uninvaded  side  during  expiration.* 

Complete  bronchial  obstruction  shows  a  density  over  the  whole 
area  the  aeration  and  drainage  of  which  has  been  cut  off  (Fig.  75). 
Pulmonary  abscess  formation  and  "drowned  lung"  (accumulated 
secretion  in  the  bronchi  and  bronchioli)  are  shown  by  the  definite 
shadows  produced  (Fig.  76). 

*  Dr.  Manges  has  developed  such  a  high  degree  of  skill  in  the  fluoroscopic  diagno- 
sis of  non-opaque  foreign  bodies  by  the  obstructive  emphysema  they  produce  that 
he  has  located  peanut  kernels  and  other  vegetable  substances  with  absolute  accuracy 
and  unfailing  certainty  in  dozens  of  cases  at  the  Bronchoscopic  Clinic. 


I40  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

Dense  and  metallic  objects  will  usually  be  readily  seen  in  the 
roentgenograms  and  fluoroscope,  but  many  foreign  bodies  are  of  a 
nature  which  will  produce  no  shadow;  the  roentgenologist  should, 
therefore,  be  prepared  to  interpret  the  pulmonary  pathology, 
and  should  not  dismiss  the  case  as  negative  for  foreign  body 


Fig.  75. — Radiograph  showing  pathology  resulting  from  complete  obstruction  of  a 
bronchus  with  atelectasis  and  drowned  lung  resulting.  Foot  of  an  alarm  clock  in  left 
bronchus  of  4  year  old  child.    Present  25  days.     Plate  made  by  Johnston  and  Grier. 

because  one  is  not  seen.     Even  metallic  objects  are  in  rare  cases 
exceedingly  difficult  to  demonstrate. 

Positive  Films  of  the  Tracheo-bronchial  Tree  as  an  Aid  to  Locali- 
zation.— In  order  to  localize  the  bronchus  invaded  by  a  small 
foreign  body  the  positive  film  is  laid  over  the  negative  of  the 
patient  showing  the  foreign  body.  The  shadow  of  the  foreign 
body  will  then  show  through  the  overlying  positive  film.  These 
positive  films  are  made  in  twelve  sizes,  and  the  size  selected  should 
be  that  corresponding  to  the  size  of  the  patient  as  shown  by  the 


FOREIGN  BODIES    IN   THE   AIR   AND    FOOD    PASSAGES 


141 


roentgenograph.  The  dome  of  the  diaphragm  and  the  dome  of  the 
pleura  are  taken  as  visceral  landmarks  for  placing  the  positive 
films  which  have  lines  indicating  these  levels.     If  the  shadow  of  the 


Fig.  76. — Partial  bronchial  obstruction  for  long  period  of  time  Pathology, 
bronchiectasis  and  pulmonary  abscess,  produced  by  the  presence  for  4  years  of  a 
nail  in  the  left  lung  of  a  boy  of  10  years 


foreign  body  be  faint  it  may  be  strengthened  by  an  ink  mark  on 
the  uncoated  side  of  the  plate. 

Bronchial  mapping  is  readily  accomplished  by  the  author's 
method  of  endobronchial  insufflation  of  a  roentgenopaque  inert 
powder  such  as  bismuth  subnitrate  or  subcarbonate  (Fig.  77). 


142  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

The  roentgenopaque  substance  may  be  injected  in  a  fluid  mixture 
if  preferred,  but  the  walls  are  better  outlined  with  the  powder 

(Fig.  77)- 


Fig.  77. — Roentgenogram  showing  the  author's  method  of  bronchial  mapping 
or  lung-mapping  by  the  bronchoscopic  introduction  of  opaque  substances  (in  this 
instance  powdered  bismuth  subnitrate)  into  the  lung  of  the  patient.  Plate  made  by 
David  R.  Bowen.  {Illustration,  strengthened  for  reproduction,  is  from  author's 
article  in  American  Journal  of  Roentgenology.  Oct.,  1918.) 

ERRORS  TO  AVOID  IN  SUSPECTED  FOREIGN  BODY  CASES 

1.  Do  not  reach  for  the  foreign  body  with  the  fingers,  lest  the 
foreign  body  be  thereby  pushed  into  the  larynx,  or  the  larynx  be 
thus  traumatized. 

2.  Do  not  hold  up  the  patient  by  the  heels,  lest  a  tracheally 
lodged  foreign  body  be  dislodged  and  asphyxiate  the  patient  by 
becoming  jammed  in  the  glottis. 


FOREIGN  BODIES    IN   THE   AIR   AND    FOOD    PASSAGES  143 

3.  Do  not  fail  to  have  a  roentgenogram  made,  if  possible, 
whether  the  foreign  body  in  question  is  of  a  kind  dense  to  the  ray 
or  not. 

4.  Do  not  fail  to  search  endoscopically  for  a  foreign  body  in 
all  cases  of  doubt. 

5.  Do  not  pass  blindly  an  esophageal  bougie,  probang,  or 
other  instrument. 

6.  Do  not  tell  the  patient  he  has  no  foreign  body  until  after 
roentgenray  examination,  physical  examination,  indirect  exami- 
nation, and  endoscopy  have  all  proven  negative. 

SUMMARY 

SYMPTOMATOLOGY  AND  DIAGNOSIS  OF  FOREIGN  BODIES  IN  THE  AIR 
AND  FOOD  PASSAGES 

Initial  symptoms  are  choking,  gagging,  coughing,  and  wheezing, 
often  followed  by  a  symptomless  interval.  The  foreign  body  may 
be  in  the  larynx,  trachea,  bronchi,  nasal  chambers,  nasopharynx, 
fauces,  tonsil,  pharynx,  hypopharynx,  esophagus,  stomach, 
intestinal  canal,  or  may  have  been  passed  by  bowel,  coughed  out 
or  spat  out,  with  or  without  the  knowledge  of  the  patient.  Initial 
choking,  etcetera  may  have  escaped  notice,  or  may  have  been 
forgotten. 

Laryngeal  Foreign  Body. — One  or  more  of  the  following  laryn- 
geal symptoms  may  be  present:  Hoarseness,  croupy  cough,  aphonia, 
odynphagia,  hemoptysis,  wheezing,  dyspnea,  cyanosis,  apnea,  sub- 
jective sensation  of  foreign  body.  Croupiness  in  foreign  body  cases, 
as  in  diphtheria,  usually  means  subglottic  swelling.  Obstructive 
foreign  body  may  be  quickly  fatal  by  laryngeal  impaction  on 
aspiration,  or  on  abortive  bechic  expulsion.  Lodgement  of  a 
non-obstructive  foreign  body  may  be  followed  by  a  symptomless 
interval.  Direct  laryngoscopy  for  diagnosis  is  indicated  in  every 
child   having   laryngeal   diphtheria   without   faucial   membrane. 


144  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

(No  anesthetic,  general  or  local  is  needed.)     In  the  presence  of 
laryngeal  symptoms,  think  of  the  following: 

1.  A  foreign  body  in  the  larynx. 

2.  A  foreign  body  loose  or  fixed  in  the  trachea. 

3.  Digital  efforts  at  removal. 

4.  Instrumentation. 

5.  Overflow  of  food  into  the  larynx  from  esophageal  obstruc- 
tion due  to  the  foreign  body. 

6.  Esophago tracheal  fistula  from  ulceration  set  up  by  a  foreign 
body  in  the  esophagus,  followed  by  the  leakage  of  food  into  the 
air-passages. 

7.  Laryngeal  symptoms  may  persist  from  the  trauma  of  a 
foreign  body  that  has  passed  on  into  the  deeper  air  or  food  passages 
or  that  has  been  coughed  or  spat  out. 

8.  Laryngeal  symptoms  (hoarseness,  croupiness,  etcetera) 
may  be  due  to  digital  or  instrumental  efforts  at  the  removal  of  a 
foreign  body  that  never  was  present. 

9.  Laryngeal  symptoms  may  be  due  to  acute  or  chronic 
laryngitis,  diphtheria,  pertussis,  infective  laryngotracheitis,  and 
many  other  diseases. 

10.  Deductive  decisions  are  dangerous. 

11.  If  the  roentgenray  is  negative,  laryngoscopy  (direct  in 
children,  indirect  in  adults)  without  anesthesia,  general  or  local, 
is  the  only  way  to  make  a  laryngeal  diagnosis. 

12.  Before  doing  a  diagnostic  laryngoscopy,  preparation 
should  be  made  for  taking  a  swab-specimen  and  for  bronchoscopy 
and  esophagoscopy. 

Tracheal  Foreign  Body. — (i)  "Audible  slap,"  (2)  "palpatory 
thud,"  and  (3)  "asthmatoid  wheeze"  are  pathognomonic.  The 
"tracheal  flutter"  has  been  observed  by  McCrae  in  a  case  of  water- 
melon seed.  Cough,  hoarseness,  dyspnea,  and  cyanosis  are  often 
present.     Diagnosis  is  by  roentgenray,  auscultation,  palpation, 


FOREIGN   BODIES    IN    THE    AIR   AND    FOOD    PASSAGES  145 

and  bronchoscopy.  Listen  long  for  "audible  slap,"  best  heard  at 
open  mouth  during  cough.  The  "asthmatoid  wheeze"  is  heard 
with  the  ear  or  stethoscope  bell  (McCrae)  at  the  patient's  open 
mouth.  History  of  initial  choking,  gagging,  and  wheezing  is 
important  if  elicited,  but  is  valueless  negatively. 

Bronchial  Foreign  Body. — -Initial  symptoms  are  coughing, 
choking,  asthmatoid  wheeze,  etc.  noted  above.  There  may  be  a 
history  of  these  or  of  tooth  extraction.  At  once,  or  after  a 
symptomless  interval,  cough,  blood-streaked  sputum,  metallic 
taste,  or  special  odor  of  foreign  body  may  be  noted.  Non-obstruc- 
tive metallic  foreign  bodies  afford  few  symptoms  and  few  signs 
for  weeks  or  months.  Obstructive  foreign  bodies  cause  atalectasis, 
drowned  lung,  and  eventually  pulmonary  abscess.  Lobar  pneu- 
monia is  an  exceedingly  rare  sequel.  Vegetable  organic  foreign 
bodies  as  peanut-kernels,  beans,  watermelon  seeds,  etcetera,  cause 
at  once  violent  laryngotracheobronchitis,  with  toxemia,  cough 
and  irregular  fever,  the  gravity  and  severity  being  inversely  to 
the  age  of  the  child.  Bones,  animal  shells  and  inorganic  bodies 
after  months  or  years  produce  changes  which  cause  chills,  fever, 
sweats,  emaciation,  clubbed  fingers,  incurved  nails,  cough,  foul 
expectoration,  hemoptysis,  in  fact,  all  the  symptoms  of  chronic 
pulmonary  sepsis,  abscess,  and  bronchiectasis.  These  symptoms 
and  some  of  the  physical  signs  may  suggest  pulmonary  tuberculosis, 
but  the  apices  are  normal  and  bacilli  are  absent  from  the  sputum. 
Every  acute  or  chronic  chest  case  calls  for  the  exclusion  of  foreign 
body. 

The  physical  signs  vary  with  conditions  present  in  different 

•cases  and  at  different  times  in  the  same  case.     Secretions,  normal 

and  pathologic,  may  shift  from  one  location  to  another;  the  foreign 

body  may  change  its  position  admitting  more,  less,  or  no  air,  or  It 

may  shift  to  a  new  location  in  the  same  lung  or  even  in  the  other 

lung.     A  recently  aspirated  pin  may  produce  no  signs  at  all.     The 
10 


146  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

signs  of  diagnostic  importance  are  chiefly  those  of  partial  or  com- 
plete bronchial  obstruction,  though  a  non-obstructive  foreign 
body,  a  pin  for  instance,  may  cause  limited  expansion  (McCrae) 
or,  rarely,  a  peculiar  rale  or  a  peculiar  auscultatory  sound.  The 
most  nearly  characteristic  physical  signs  are:  (i)  Limited  expan- 
sion; (2)  decreased  vocal  fremitus;  (3)  impaired  percussion  note; 
(4)  diminished  intensity  of  the  breath-sounds  distal  to  the  foreign 
body.  Complete  obstruction  of  a  bronchus  followed  by  drowned 
lung  adds  absence  of  vocal  resonance  and  vocal  fremitus,  thus  often 
leading  to  an  erroneous  diagnosis  of  empyema.  Varying  grades 
of  tympany  are  obtained  over  areas  of  obstructive  or  compensatory 
emphysema.  With  complete  obstruction  there  may  be  tympany 
from  the  collapsed  lung  for  a  time.  Rales  in  case  of  complete 
obstruction  are  usually  most  intense  on  the  uninvaded  side.  In 
partial  obstruction  they  are  most  often  found  on  the  invaded  side 
distal  to  the  foreign  body,  especially  posteriorly,  and  are  most 
intense  at  the  site  corresponding  to  that  of  the  foreign  body.  A 
foreign  body  at  the  bifurcation  of  the  trachea  may  give  signs  in 
both  lungs.  Early  in  a  foreign  body  case,  diminished  expansion 
of  one  side,  with  dulness,  may  suggest  pneumonia  in  the  affected 
side;  but  absence  of,  or  decreased,  vocal  resonance,  and  absence 
of  typical  tubular  breathing  should  soon  exclude  this  diagnosis. 
Bronchial  obstruction  in  pneumonia  is  exceedingly  rare. 
Memorize  these  signs  suggestive  of  foreign  body: 

1.  Expansion — diminished. 

2.  Percussion  note — impaired  (except  in  obstructive  emphy- 
sema) . 

3 .  Vocal  fremitus — diminished. 

4.  Breath  sounds — diminished. 

The  foregoing  is  only  for  memorizing,  and  must  be  considered 
in  the  light  of  the  following  fundamental  note  by  Prof.  McCrae 
''There  is  no  one  description  of  physical  signs  which  covers 


FOREIGN   BODIES    IN    THE    AIR    AND    POOD    PASSAGES  147 

all  cases.  If  the  student  will  remember  that  complete  obstruction 
of  a  bronchus  leads  to  a  shutting  off  of  this  area,  there  should  be 
little  difficulty  in  understanding  the  signs  present.  The  diagnosis 
of  empyema  may  be  made,  but  the  outline  of  the  area  of  dulness, 
the  fact  that  there  is  no  shifting  dulness,  and  the  greater  resis- 
tance which  is  present  in  empyema  nearly  always  clear  up  any 
difficulty  promptly.  The  absence  of  the  frequent  change  in  the 
voice  sounds,  so  significant  in  an  early  small  empyema,  is  of  value. 
A  large  empyema  should  give  no  difficulty.  If  difficulty  re- 
mains the  use  of  the  needle  should  be  sufficient.  In  thickened 
pleura  vocal  fremitus  is  not  entirely  absent,  and  the  breath- 
sounds  can  usually  be  heard,  even  if  diminished.  In  case  of  partial 
obstruction  of  a  bronchus,  it  is  evident  that  air  will  still  be  present, 
hence  the  dulness  may  be  only  slight.  The  presence  of  air  and 
secretion  will  probably  result  in  the  breath-sounds  being  somewhat 
harsh,  and  will  cause  a  great  variety  of  rales,  principally  coarse, 
and  many  of  them  bubbling.  Difficulty  may  be  caused  by  signs 
in  the  other  lung  or  in  a  lobe  other  than  the  one  affected  by  the 
foreign  body.  If  it  is  remembered  that  these  signs  are  likely  to  be 
only  on  auscultation,  and  to  consist  largely  in  the  presence  of 
rales,  while  the  signs  in  the  area  supplied  by  the  affected  bronchus 
will  include  those  on  inspection,  palpation,  and  percussion,  there 
should  be  little  difficulty." 

The  roentgenray  is  the  most  valuable  diagnositic  means;  but 
careful  notation  of  physical  signs  by  an  expert  should  be  made  in 
all  cases  preferably  without  knowledge  of  ray  findings.  Expert 
ray  work  will  show  all  metallic  foreign  bodies  and  many  of  less 
density,  such  as  teeth,  bones,  shells,  buttons,  etcetera.  If  the 
ray  is  negative,  a  diagnostic  bronchoscopy  should  be  done  in  all 
cases  of  unexplained  bronchial  obstruction. 

Peanut  kernels  and  watermelon  seeds  and,  rarely,  other 
foreign  bodies  in  the  bronchi  produce  obstructive  emphysema  of 


148  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

the  invaded  side.  Fluoroscopy  shows  the  diaphragm  flattened, 
depressed  and  of  less  excursion  on  the  invaded  side;  at  the  end  of 
expiration,  the  heart  and  the  mediastinal  wall  move  over  toward 
the  uninvaded  side  and  the  invaded  lung  becomes  less  dense 
than  the  uninvaded  lung,  from  the  trapping  of  the  air  by  the 
expiratory,  valve-like  effect  of  obliteration  of  the  "forceps  spaces" 
that  during  inspiration  afford  air  ingress  between  the  foreign 
body  and  the  swollen  bronchial  wall.  This  partial  obstruction 
causes  obstructive  emphysema,  which  must  be  distinguished  from 
compensatory  emphysema,  in  which  the  ballooning  is  in  the  unob- 
structed lung,  because  its  fellow  is  wholly  out  of  function  through 
complete  "corking"  of  the  main  bronchus  of  the  invaded  side. 

Esophageal  Foreign  Body. — After  initial  choking  and  gagging, 
or  without  these,  there  may  be  a  subjective  sense  of  a  foreign 
body,  constant  or,  more  often,  on  swallowing.  Odynphagia  and 
dysphagia  or  aphagia  may  or  may  not  be  present.  Pain,  sub- 
sternal or  extending  to  the  back  is  sometimes  present.  Hematem- 
esis  and  fever  may  occur  from  the  foreign  body  or  from  rough 
instrumentation.  Symptoms  referable  to  the  air-passages  may  be 
present  due  to:  (i)  Overflow  of  the  secretions  on  attempts  to 
swallow  through  the  obstructed  esophagus;  (2)  erosion  of  the 
foreign  body  through  from  the  esophagus  into  the  trachea;  or  (3) 
trauma  inflicted  on  the  larynx  during  attempts  at  removal,  digital 
or  instrumental,   the  foreign  body   still  being  present  or  not. 

Diagnosis  is  by  the  roentgenray,  first  without,  then,  if  neces- 
sary, with  a  capsule  filled  with  an  opaque  mixture.  Flat  objects, 
like  coins,  always  lie  with  their  greatest  diameter  in  the  coronal 
plane  of  the  body,  when  in  the  esophagus;  in  the  sagittal  plane, 
when  in  the  trachea  or  larynx.  Lateral,  anteroposterior,  and 
sometimes  also  quartering  roentgenograms  are  necessary.  One 
taken  laterally,  low  down  on  the  neck  but  clear  of  the  shoulder, 
will  often  show  a  bone  or  other  semiopaque  object  invisible  in 
the  anteroposterior  exposure. 


CHAPTER  XIII 

FOREIGN  BODIES  IN  THE  LARYNX  AND  TRACHEOBRON- 
CHIAL TREE 

The  protective  reflexes  preventing  the  entrance  of  foreign 
bodies  into  the  lower  air  passages  are:  (i)  The  laryngeal  closing 
reflex  and  (2)  the  bechic  reflex.  Laryngeal  closing  for  normal 
swallowing  consists  chiefly  in  the  tilting  and  the  closure  of  the 
upper  laryngeal  orifice.  The  ventricular  bands  help  but  slightly; 
and  the  epiglottis  and  the  vocal  cords  little,  if  at  all.  The  gauntlet 
to  be  run  by  foreign  bodies  entering  the  tracheobronchial  tree  is 
composed  of: 

1.  Epiglottis. 

2.  Upper  laryngeal  orifice. 

3.  Ventricular  bands. 

4.  Vocal  cords. 

5.  Bechic  blast. 

The  epiglottis  acts  somewhat  as  a  fender.  The  superior 
laryngeal  aperture,  composed  of  a  pair  of  movable  ridges  of  tissue, 
has  almost  a  sphincteric  action,  in  addition  to  a  tilting  movement. 
The  ventricular  bands  can  approximate  under  powerful  stimuli. 
The  vocal  cords  act  similarly.  The  one  defect  in  the  efficiency 
of  this  barrier,  is  the  tendency  to  take  a  deep  inspiration  prepara- 
tory to  the  cough  excited  by  the  contact  of  a  foreign  body. 

Site  of  Lodgment. — The  majority  of  foreign  bodies  in  the  air 
passages  occur  in  children.  The  right  bronchus  is  more  frequently 
invaded  than  the  left  because  of  the  following  factors:  i.  Its 
greater  diameter.  2.  Its  lesser  angle  of  deviation  from  the 
tracheal  axis.  3.  The  situation  of  the  carina  to  the  left  of  the  mid- 
line  of   the   trachea.     4.  The   action   of    the  trachealis  muscle. 

149 


ISO  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

5.  The  greater  volume  of  air  going  into  the  right  bronchus  on 
inspiration. 

The  middle  lobe  bronchus  is  rarely  invaded  by  foreign  body, 
and,  fortunately,  in  less  than  one  per  cent  of  the  cases  is  the  object 
in  an  upper  lobe  bronchus. 

Spontaneous  Expulsion  of  Foreign  Bodies  from  the  Air  Passages. 
A  large,  light,  foreign  body  in  the  larynx  or  trachea  may  occa- 
sionally be  coughed  out,  but  the  frequent  newspaper  accounts  of 
the  sudden  death  of  children  known  to  have  aspirated  objects 
should  teach  us  never  to  wait  for  this  occurrence.  The  cause  of 
death  in  these  cases  is  usually  the  impaction  of  a  large  foreign 
body  in  the  glottis  producing  sudden  asphyxiation,  and  in  a  certain 
proportion  of  these  cases  the  impaction  has  occurred  on  the  reverse 
journey,  when  cough  forced  the  intruder  upward  from  below. 
The  danger  of  subglottic  impaction  renders  it  imperative  that 
attempts  to  aid  spontaneous  expulsion  by  inverting  the  patient 
should  be  discouraged.  Sharp  objects,  such  as  pins,  are  rarely 
coughed  out.  The  tendency  of  all  foreign  bodies  is  to  migrate 
down  and  out  to  the  periphery  as  their  size  and  shape  will  allow. 
Most  of  the  reported  cases  of  bechic  expulsion  of  bronchially 
lodged  foreign  bodies  have  occurred  after  a  prolonged  sojourn  of 
the  object,  associated  which  much  lung  pathology;  and  in  some 
cases  the  object  has  been  carried  out  along  with  an  accumulation 
of  pus  suddenly  liberated  from  an  abscess  cavity,  and  expelled  by 
cough.  This  is  a  rare  sequence  compared  to  the  usual  formation 
of  fibrous  stricture  above  the  foreign  body  that  prevents  the  possi- 
bility of  bechic  expulsion.  To  delay  bronchoscopy  with  the  hope 
of  such  a  solution  of  the  problem  is  comparable  to  the  former 
dependence  on  nature  for  the  cure  of  appendiceal  abscess. 

We  do  our  full  duty  when  we  tell  the  patient  or  parents  that 
while  the  foreign  body  may  be  coughed  up,  it  is  very  dangerous 
to    wait;    and,   further,   that  the  difficulty  of    removal  usually 


FOREIGN  BODIES  IN  THE  LARYNX  151 

increases  with  the  time  the  foreign  body  is  allowed  to  remain  in 
the  air  passages. 

Mortality  and  morbidity  of  bronchoscopy  vary  directly  with  the 
degree  of  skill  and  experience  of  the  operator,  and  the  conditions 
for  which  the  endoscopies  are  performed.  The  simple  insertion 
of  the  bronchoscope  is  devoid  of  harm  if  carefully  done.  The 
danger  lies  in  misdirected  efforts  at  removal  of  the  intruder  and 
in  repeating  bronchoscopies  in  children  at  too  frequent  intervals, 
or  in  prolonging  the  procedure  unduly.  In  children  under  one 
year  endoscopy  should  be  limited  to  twenty  minutes,  and  should 
not  be  repeated  sooner  than  one  week  after,  unless  urgently  indi- 
cated. A  child  of  5  years  will  bear  40  to  60  minutes  work,  while 
the  adult  offers  no  unvarying  time  limit.  More  can  be  ultimately 
accomplished,  and  less  reaction  will  follow  short  endoscopies 
repeated  at  proper  intervals  than  in  one  long  procedure. 

Indications  for  bronchoscopy  for  suspected  foreign  body  may  be 
thus  summarized: 

1.  The  appearance  of  a  suspicious  shadow  in  the  radiograph, 
in  the  line  of  a  bronchus. 

2.  In  any  case  in  which  lung  symptoms  followed  a  clear  history 
of  the  patient  having  choked  on  a  foreign  body. 

3.  In  any  case  showing  signs  of  obstruction  in  the  trachea 
or  of  a  bronchus. 

4.  In  suspected  bronchiectasis. 

5.  Symptoms  of  pulmonary  tuberculosis  with  sputum  con- 
stantly negative  for  tubercle  bacilli.  If  the  physical  signs  are  at 
the  base,  particularly  the  right  base,  the  indication  becomes  very 
strong  even  in  the  absence  of  any  foreign  body  circumstance  in 
the  history. 

6.  In  all  cases  of  doubt,  bronchoscopy  should  be  done  anyway. 
There    is    no    absolute    contraindication    to    bronchoscopy  for 

foreign  bodies.     Extreme  exhaustion  or  reaction  from  previous 


«.  I 


152  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

efforts  at  removal  may  call  for  delay  for  recuperation,  but  pul- 
monary abscess  and  even  the  rarer  complications,  bronchopneu- 
monia and  gangrene  of  the  lung,  are  improved  by  the  early  removal 
of  the  foreign  body. 

Choice  of  Time  to  do  Bronchoscopy  for  Foreign  Body. — The 
difficulties  of  removal  usually  increase  from  the  time  of  aspiration 
of  the  object.  It  tends  to  work  downward  and  outward,  while  the 
mucosa  becomes  edematous,  partly  closing  over  the  foreign  body, 
and  even  completely  obliterating  the  lumen  of  smaller  bronchi. 
Later,  granulation  tissue  and  the  formation  of  stricture  further 
hide  the  object.  The  patient's  health  deteriorates  with  the  onset 
of  pulmonary  pathology,  and  renders  him  a  less  favorable  subject 
for  bronchoscopy.  Organic  foreign  bodies,  which  produce  early 
and  intense  inflammatory  reaction  and  are  liable  to  swell,  call  for 
prompt  bronchoscopy.  When  a  bronchus  is  completely  obstructed 
by  the  bulk  of  the  foreign  body  itself  immediate  removal  is  urgently 
demanded  to  prevent  serious  lung  changes,  resulting  from  atelec- 
tasis and  want  of  drainage.  In  short,  removal  of  the  foreign  body 
should  be  accomplished  as  soon  as  possible  after  its  entrance. 
This,  however,  does  not  justify  hasty,  ill-planned,  and  poorly 
equipped  bronchoscopy,  which  in  most  cases  is  doomed  to  failure 
in  removal  of  the  object.  The  bronchoscopist  should  not  permit 
himself  to  be  stampeded  into  a  bronchoscopy  late  at  night, 
when  he  is  fatigued  after  a  hard  day's  work. 

Bronchoscopic  finding  of  a  foreign  body  is  not  especially  difiicult 
if  the  aspiration  has  been  recent.  If  secondary  processes  have 
developed,  or  the  object  be  small  and  in  a  bronchus  too  small  to 
admit  the  tube-mouth,  considerable  experience  may  be  necessary 
to  discover  it.  There  is  usually  inflammatory  reaction  around  the 
orifice  of  the  invaded  bronchus,  which  in  a  measure  serves  to 
localize  the  intruder.  We  must  not  forget,  however,  that  objects 
may  have  moved  to  another  location,  and  also  that  the  irritation 


FOREIGN   BODIES    IN    THE    LARYNX  1 53 

may  have  been  the  result  of  previous  efforts  at  removal.  Care 
must  be  exercised  not  to  mistake  the  sharp,  shining,  interbronchial 
spurs  for  bright  thin  objects  like  new  pins  just  aspirated;  after  a 
few  days  pins  become  blackened.  If  these  spurs  be  torn  pneumo- 
thorax may  ensue.  If  a  number  of  small  bronchi  are  to  be 
searched,  the  bronchoscope  must  be  brought  into  the  line  of  the 
axis  of  the  bronchus  to  be  examined,  and  any  intervening  tissue 
gently  pushed  aside  with  the  lip  of  the  bronchoscope.  Blind 
probing  for  exploration  is  very  dangerous  unless  carefully  done. 
The  straight  forceps,  introduced  closed,  form  the  best  probe  and 
are  ready  for  grasping  if  the  object  is  felt.  Once  the  bronchoscope 
has  been  introduced,  it  should  not  be  withdrawn  until  the  proce- 
dure is  completed.  The  light  carrier  alone  may  be  removed  from 
its  canal  if  the  illumination  be  faulty. 

COMPLICATIONS  AND  AFTER-EFFECTS  OF  BRONCHOSCOPY 

All  foreign  body  cases  should  be  watched  day  and  night  by 
special  nurses  until  all  danger  of  complications  is  passed.  Com- 
plications are  rare  after  careful  work,  but  if  they  do  occur,  they 
may  require  immediate  attention.  This  applies  especially  to 
the  subglottic  edema  associated  with  arachidic  bronchitis  in 
children  under  2  years  of  age. 

General  Reaction. — -There  is  usually  no  elevation  in  temperature 
following  a  short  bronchoscopy  for  the  removal  of  a  recently 
lodged  metallic  foreign  body.  If,  however,  an  inflammatory 
condition  of  the  bronchi  existed  previous  to  the  bronchoscopy, 
as  for  instance  the  intense  diffuse,  purulent  laryngo-tracheo- 
bronchitis  associated  with  the  aspiration  of  nut  kernels,  or  in  the 
presence  of  pulmonary  abscess  from  long  retained  foreign  bodies, 
a  moderate  temporary  rise  of  temperature  may  be  expected. 
These  cases  almost  always  have  had  irregular  fever  before  bron- 
choscopy.    Disturbance  of  the  epithelium  in  the  presence  of  pus 


154  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

without  abscess  usually  permits  enough  absorption  to  elevate  the 
temperature  slightly  for  a  few  days. 

Surgical  shock  in  its  true  form  has  never  followed  a  carefully 
performed  and  time-limited  bronchoscopy.  Severe  fatigue  result- 
ing in  deep  sleep  may  be  seen  in  children  after  prolonged  work. 

Local  reaction  is  ordinarily  noted  by  slight  laryngeal  congestion 
causing  some  hoarseness  and  disappearing  in  a  few  days.  If 
dyspnea  occur  it  is  usually  due  to  (i)  Drowning  of  the  patient  in 
his  own  secretions.     (2)  Subglottic  edema.     (3)  Laryngeal  edema. 

Drowning  of  the  Patient  in  His  Own  Secretions. — The  accumula- 
tion of  secretions  in  the  bronchi  due  to  faulty  bechic  powers 
and  seen  most  frequently  in  children,  is  quickly  relievable  by 
bronchoscopic  sponge-pumping  or  aspiration  through  the  trache- 
otomic  wound,  in  cases  in  which  the  tracheotomy  may  be  deemed 
necessary.  In  other  cases,  the  aspirating  bronchoscope  with 
side  drainage  canal  (Fig.  i,  E)  may  be  used  through  the  larynx. 
Frequent  peroral  passage  of  the  bronchoscope  for  this  purpose  is 
contraindicated  only  in  case  of  children  under  3  years  of  age, 
because  of  the  likelihood  of  provoking  subglottic  edema.  In 
such  cases  instead  of  inserting  a  bronchoscope  the  aspirating  tube 
(Fig.  9)  should  be  inserted  through  the  direct  laryngoscope, 
or  a  low  tracheotomy  should  be  done. 

Supraglottic  edema  is  rarely  responsible  for  dyspnea  except 
when  associated  with  advanced  nephritis. 

Subglottic  edema  is  a  complication  rarely  seen  except  in  children 
under  3  years  of  age.  They  have  a  peculiar  histologic  structure 
in  this  region,  as  is  shown  by  Logan  Turner.  Even  at  the  predis- 
posing age  subglottic  edema  is  a  very  unusual  sequence  to  bron- 
choscopy if  this  region  was  previously  normal.  The  passage  of  a 
bronchoscope  through  an  already  inflamed  subglottic  area  is 
liable  to  be  followed  by  a  temporary  increase  in  the  swelling.  If 
the  foreign  body  be  associated  with  but  slight  amount  of  secretion, 


FOREIGN   BODIES    IN    THE    LARYNX  1 55 

the  child  can  usually  obtain  sufficient  air  through  the  temporarily 
narrowed  lumen.  If,  however,  as  in  cases  of  arachidic  bronchitis, 
large  amounts  of  purulent  secretion  must  be  expelled,  it  will  be 
found  in  certain  cases  that  the  decreased  glottic  lumen  and  im- 
paired laryngeal  motility  will  render  tracheotomy  necessary  to 
drain  the  lungs  and  prevent  drowning  in  the  retained  secretions. 
Subglottic  edema  occurring  in  a  previously  normal  larynx  may 
result  from:  i.  The  use  of  over-sized  tubes.  2.  Prolonged  bron- 
choscopy. 3.  Faulty  position  of  the  patient,  the  axis  of  the  tube 
not  being  in  that  of  the  trachea.  4.  Trauma  from  undue  force  or 
improper  direction  in  the  insertion  of  the  bronchoscope.  5. 
The  manipulation  of  instruments.  6.  Trauma  inflicted  in  the 
extraction  of  the  foreign  body. 

Diagnosis  must  be  made  without  waiting  for  cyanosis  which 
may  never  appear.  Pallor,  restlessness,  startled  awakening  after 
a  few  minutes  sleep,  occurring  in  a  child  with  croupy  cough, 
indrawing  around  the  clavicles,  in  the  intercostal  spaces,  at  the 
suprasternal  notch  and  at  the  epigastrium,  call  for  tracheotomy 
which  should  always  be  low.  Such  a  case  should  not  be  left 
unwatched.  The  child  will  become  exhausted  in  its  fight  for  air 
and  will  give  up  and  die.  The  respiratory  rate  naturally  increases 
because  of  air  hunger,  accumulating  secretions  that  cannot 
be  expelled  because  of  impaired  glottic  motility  give  signs  wrongly 
interpreted  as  pneumonia.  Many  children  whose  lives  could 
have  been  saved  by  tracheotomy  have  died  under  this  erroneous 
diagnosis. 

Treatment. — Intubation  is  not  so  safe  because  the  secretions 
cannot  easily  be  expelled  through  the  tube  and  postintubational 
stenosis  may  be  produced.  Low  tracheotomy,  the  tracheal  inci- 
sion always  below  the  second  ring,  is  the  safest  and  best  method 
of  treatment. 


CHAPTER  XIV 
REMOVAL    OF    FOREIGN    BODIES    FROM    THE    LARYNX 

Symptoms  and  Diagnosis. — The  history  of  a  sudden  choking 
attack  followed  by  impairment  of  voice,  wheezing,  and  more  or 
less  dyspnea  can  be  usually  elicited.  Laryngeal  diphtheria  is  the 
condition  most  frequently  thought  of  when  these  symptoms  are 
present,  and  antitoxin  is  rightly  given  while  waiting  for  a  positive 
diagnosis.  Extreme  dyspnea  may  render  tracheotomy  urgently 
demanded  before  any  attempts  at  diagnosis  are  made.  Further 
consideration  of  the  symptomatology  and  diagnosis  of  laryngeal 
foreign  body  will  be  found  on  pages  128,  133  and  143. 

Preliminary  Examination. — In  the  adult,  mirror  examination 
of  the  larynx  should  be  done,  the  patient  being  placed  in  the  recum- 
bent position.  Whenever  time  permits  roentgenograms,  lateral 
and  anteroposterior,  should  be  made,  the  lateral  one  as  low  in  the 
neck  as  possible.  One  might  think  this  an  unnecessary  procedure 
because  of  the  visibility  of  the  larynx  in  the  mirror;  but  a  child's 
larynx  cannot  usually  be  indirectly  examined,  and  even  in  the  adult 
a  pin  may  be  so  situated  that  neither  head  nor  point  is  visible^ 
only  a  portion  of  the  shaft  being  seen.  The  roentgenogram  will 
give  accurate  information  as  to  the  position,  and  will  thus  allow  a 
planning  of  the  best  method  for  removal  of  the  foreign  body. 
A  bone  in  the  larynx  usually  is  visible  in  a  good  roentgenogram. 
Accurate  diagnosis  in  children  is  made  by  direct  laryngoscopy 
without  anesthesia,  but  direct  laryngoscopy  should  not  be  done 
until  one  is  prepared  to  remove  a  foreign  body  if  found,  to  follow 
it  into  the  bronchus  and  remove  it  if  it  should  be  dislodged  and 

aspirated,  and  to  do  tracheotomy  if  sudden  respiratory  arrest  occur. 

156 


REMOVAL    OF    FOREIGN   BODIES    FROM    THE    LARYNX  1 57 

Technic  of  Removal  of  Foreign  Bodies  from  the  Larynx. — The 
patient  is  to  be  placed  in  the  author's  position,  shown  in  Fig.  53. 
No  general  anesthesia  should  be  given,  and  the  application  of 
local  anesthesia  is  usually  unnecessary  and  further,  is  liable  to 
dislodge  and  push  down  the  foreign  body.*  Because  of  the  risk 
of  loss  downward  it  is  best  to  seize  the  foreign  body  as  soon  as  seen; 
then  to  determine  how  best  to  disimpact  it.  The  fundamental 
principles  are  that  a  pointed  object  must  either  have  its  point  pro- 
tected by  the  forceps  grasp  or  be  brought  out  point  trailing,  and 
that  a  flat  object  must  be  so  rotated  that  its  plane  corresponds  to 
the  sagittal  plane  of  the  glottic  chink.  The  laryngeal  grasping 
forceps  (Fig.  53)  will  be  found  the  most  useful,  although  the  alliga- 
tor rotation  forceps  (Fig.  31)  may  occasionally  be  required. 

*  In  adolescents  or  adults  a  few  drops  of  a  4  per  cent  solution  of  cocain  applied  to 
the  laryngopharynx  with  an  atomizer  or  a  dropper  will  afford  the  minimum  risk  of 
dislodge  men  t;  but  the  author's  personal  preference  is  for  no  anesthesia,  general  or 
local. 


CHAPTER  XV 

MECHANICAL  PROBLEMS  OF  BRONCHOSCOPIC  FOREIGN 
BODY  EXTRACTION* 

The  endoscopic  extraction  of  a  foreign  body  is  a  mechanical 
problem  pure  and  simple,  and  must  be  studied  from  this  viewpoint. 
Hasty,  ill-equipped,  ill-planned,  or  violent  endoscopy  on  the  erron- 
eous principle  that  if  not  immediately  removed  the  foreign  body 
will  be  fatal,  is  never  justifiable.  While  the  lodgement  of  an 
organic  foreign  body  (such  as  a  nut  kernel)  in  the  bronchus  calls 
for  prompt  removal  and  might  be  included  under  the  list  of  emer- 
gency operations,  time  is  always  available  for  complete  preparation, 
for  thorough  study  of  the  patient,  and  localization  of  the  intruder. 
The  patient  is  better  off  with  the  foreign  body  in  the  lung  than  if 
in  its  removal  a  mediastinitis,  rupture  into  the  pleura,  or  tearing 
of  a  thoracic  blood  vessel  has  resulted.  The  motto  of  the  endo- 
scopist should  be  "I  will  do  no  harm."  If  no  harm  be  inflicted, 
any  number  of  bronchoscopies  can  be  done  at  suitable  intervals, 
and  eventually  success  will  be  achieved,  whereas  if  mortality 
results,  all  opportunity  ceases. 

The  first  step  in  the  solution  of  the  mechanical  problem  is 
the  study  of  the  roentgenograms  made  in  at  least  three  planes; 
(i)  anteroposterior,  (2)  lateral,  and  (3)  the  plane  corresponding 
to  the  greatest  plane  of  the  foreign  body.  The  next  step  is  to 
put  a  duplicate  of  the  foreign  body  into  the  rubber-tube  manikin 
previously  referred  to,  and  try  to  simulate  the  probable  position 
shown  by  the  ray,  so  as  to  get  an  idea  of  the  bronchoscopic  appear- 
ance of  the  probable  presentation.  Then  the  duplicate  foreign 
body  is  turned  into  as  many  different  positions  as  possible,  so  as 
to  educate  the  eye  to  assist  in  the  comprehension  of  the  largest 

*  For  more  extensive  consideration  of  mechanical  problems  than  is  here  possible 
the  reader  is  referred  to  the  Bibliography,  page  311,  especially  reference  numbers 
I,  II,  37  and  56. 

158 


BRONCHOSCOPIC    FOREIGN   BODY    EXTRACTION  1 59 

possible  number  of  presentations  that  may  be  encountered  at  the 
bronchoscopy  on  the  patient.  For  each  of  these  presentations 
a  method  of  disimpaction,  disengagement,  disentanglement  or 
version  and  seizure  is  worked  out,  according  to  the  kind  of  foreign 
body.  Prepared  by  this  practice  and  the  radiographic  study,  the 
bronchoscope  is  introduced  into  the  patient.  The  location  of  the 
foreign  body  is  approached  slowly  and  carefully  to  avoid  overrid- 
ing or  displacement.  A  study  of  the  presentation  is  as  necessary 
for  the  bronchoscopist  as  for  the  obstetrician.  It  should  be  made 
with  a  view  to  determining  the  following  points : 

1.  The  relation  of  the  presenting  part  to  the  surrounding 
tissues. 

2.  The  probable  position  of  the  unseen  portion,  as  determined 
by  the  appearance  of  the  presenting  part  taken  in  connection  with 
the  knowledge  obtained  by  the  previous  ray  study,  and  by  inspec- 
tion of  the  ray  plate  upside  down  on  view  in  front  of  the  broncho- 
scopist. 

3.  The  version  or  other  manipulation  necessary  to  convert  an 
unfavorable  into  a  favorable  presentation  for  grasping  and 
disengagement. 

4.  The  best  instruments  to  use,  and  which  to  use  first,  as, 
hook,  pincloser,  forceps,  etc. 

5.  The  presence  and  position  of  the  "forceps  spaces"  of  which 
there  must  be  two  for  all  ordinary  forceps,  one  for  each  jaw,  or 
the  "insertion  space"  for  any  other  instrument. 

Until  all  of  these  points  are  determined  it  is  a  grave  error  to 
insert  any  kind  of  instrument.  If  possible  even  swabbing  of  the 
foreign  body  should  be  avoided  by  swabbing  out  the  bronchus, 
when  necessary,  before  the  region  of  the  intruder  is  reached. 
When  the  operator  has  determined  the  instrument  to  be 
used,  and  the  method  of  using  it,  the  instrument  is  cautiously 
inserted,  under  guidance  of  the  eye. 


l6o  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

The  lip  of  the  bronchoscope  is  one  of  the  most  valuable  aids  in 
the  solution  of  foreign-body  problems.  With  it  partial  or  com- 
plete version  of  an  object  can  be  accomplished  so  as  to  convert  an 
unfavorable  presentation  into  one  favorable  for  grasping  with  the 
forceps;  edematous  mucosa  may  be  displaced,  angles  straightened 
and  space  made  at  the  side  of  the  foreign  body  for  the  forceps' 
jaw.  It  forms  a  shield  or  protector  that  can  be  sHpped  under  the 
point  of  a  sharp  foreign  body  and  can  make  counterpressure  on  the 
tissues  while  the  forceps  are  disembedding  the  point  of  the  foreign 
body.  With  the  bronchoscopic  lip  and  the  forceps  or  other 
instrument  inserted  through  the  tube,  the  bronchoscopist  has 
bimanual,  eye-guided  control,  which  if  it  has  been  sufficiently 
practiced  to  afford  the  facility  in  coordinate  use  common  to 
everyone  with  knife  and  fork,  will  accomplish  maneuvers  that  seem 
marvelous  to  anyone  who  has  not  developed  facility  in  this  coordi- 
nate use  of  the  bronchoscopic  instruments. 

The  relation  of  the  tube  mouth  and  foreign  body  is  of  vital  impor- 
tance. Generally  considered,  the  tube  mouth  should  be  as  near 
the  foreign  body  as  possible,  and  the  object  must  be  placed  in  the 
center  of  the  bronchoscopic  field,  so  that  the  ends  of  the  open  jaws 
of  the  forceps  will  pass  sufficiently  far  over  the  object.  But  little 
lateral  control  is  had  of  the  long  instruments  inserted  through  the 
tube;  sidewise  motion  is  obtained  by  a  shifting  of  the  end  of  the 
bronchoscope.  When  the  foreign  body  has  been  centered  in 
the  bronchoscopic  field  and  placed  in  a  position  favorable  for 
grasping,  it  is  important  that  this  position  be  maintained  by 
anchoring  the  tube  to  the  upper  teeth  with  the  left,  third,  and 
fourth  fingers  hooked  over   the  patient's  upper  alveolus  (Fig. 

63). 

The  Light  Reflex  on  the  Forceps. — It  is  often  difficult  for  the 
beginner  to  judge  to  what  depth  an  instrument  has  been  inserted 
through  the  tube.     On  slowly  inserting  a  forceps  through  the  tube, 


BRONCHOSCOPIC   FOREIGN  BODY   EXTRACTION  l6l 

as  the  blades  come  opposite  the  distal  light  they  will  appear 
brightly  illuminated;  or  should  the  blades  lie  close  to  the  light 
bulb,  a  shadow  will  be  seen  in  the  previously  brilliantly  lighted 
opposite  wall.  It  is  then  known  that  the  forceps  are  at  the  tube 
mouth,  and  the  endoscopist  has  but  to  gauge  the  distance  from  this 
to  the  foreign  body.  This  assitance  in  gauging  depth  is  one  of  the 
great  advances  in  foreign  body  bronchoscopy  obtained  by  the 
development  of  distal  illumination. 

Hooks  are  useful  in  the  solution  of  various  mechanical  prob- 
lems, and  may  be  turned  by  the  operator  himself  into  various 
shapes  by  heating  small  probe-pointed  steel  rods  in  a  spirit  lamp, 
the  proximal  end  being  turned  over  at  a  right  angle  for  a  control- 
ling handle.  Hooks  with  a  greater  curve  than  a  right  angle  are 
prone  to  engage  in  small  orifices  from  which  they  are  with  difl&culty 
removed.  A  right  angle  curve  of  the  distal  end  is  usually  suffi- 
cient, and  a  corkscrew  spiral  is  often  advantageous,  rendering 
removal  easy  by  a  reversal  of  the  twisting  motion  (Bib.  ii,  p.  311). 

The  Use  of  Forceps  in  Endoscopic  Foreign  Body  Extraction. — 
Two  different  strengths  of  forceps  are  supplied,  as  will  be  seen  in 
the  list  in  Chapter  I.  The  regular  forceps  have  a  powerful  grasp 
and  are  used  on  dense  foreign  bodies  which  require  considerable 
pressure  on  the  object  to  prevent  the  forceps  from  slipping  off. 
For  more  delicate  manipulation,  and  particularly  for  friable  foreign 
bodies,  the  lighter  forceps  are  used.  Spring-opposed  forceps 
render  any  delicacy  of  touch  impossible.  Forceps  are  to  be  held 
in  the  right  hand,  the  thumb  in  one  ring,  and  the  third,  or  ring 
finger,  in  the  other  ring.  These  fingers  are  used  to  open  and  close 
the  forceps,  while  all  traction  is  to  be  made  by  the  right  index 
finger,  which  has  its  position  on  the  forceps  handle  near  the  stylet, 
as  shown  in  Fig.  78.  It  is  absolutely  essential  for  accurate  work, 
that  the  forceps  jaws  be  seen  to  close  upon  the  foreign  body.     The 

impulse  to  seize  the  object  as  soon  as  it  is  discovered  must  be 

11 


l62 


BRONCHOSCOPY  AND  ESOPHAGOSCOPY 


strongly  resisted.  A  careful  study  of  its  size,  shape,  and  position 
and  relation  to  surrounding  structures  must  be  made  before  any 
attempt  at  extraction.  The  most  favorable  point  and  position 
for  grasping  having  been  obtained,  the  closed  forceps  are  inserted 
through  the  bronchoscope,  the  light  reflex  obtained,  the  forceps 
blades  now  opened  are  turned  in  such  a  position  that,  on  advancing, 


Xi'act'ioi-t   bL| 
in  d\reciloi-i  oto'ari 


Traction  nol  maJiei, 


Fig.  78. — Proper  hold  of  forceps.  The  right  thumb  and  third  fingers  are  in- 
serted into  the  rings  while  the  right  index  finger  has  its  place  high  on  the  handle. 
All  traction  is  made  with  the  index  finger,  the  ring  fingers  be'ing  used  only  to  open 
and  close  the  forceps.  If  any  pushing  is  deemed  safe  it  may  be  done  by  placing  the 
index  finger  back  of  the  thumb-nut  on  the  stylet. 


the  foreign  body  will  enter  the  open  V,  a  sufficient  distance  to 
afford  a  good  grasp.  The  blades  are  then  closed  and  the  foreign 
body  is  drawn  against  the  tube  mouth.  Few  foreign  bodies  are 
sufficiently  small  to  allow  withdrawal  through  the  tube,  so  that 
tube,  forceps  and  foreign  body  are  usually  withdrawn  together. 
Anchoring  the  Foreign  Body  Against  the  Tube  Mouth. — If 
withdrawal  be  made  a  bimanual  procedure  it  is  almost  certain  that 
the  foreign  body  will  trail  a  centimeter  or  more  beyond  the  tube 
mouth,  and  that  the  closure  of  the  glottic  chink  as  soon  as  the 


BRONCHOSCOPIC    FOREIGN   BODY    EXTRACTION 


163 


distal  end  of  the  bronchoscope  emerges  will  strip  the  foreign  body 
from  the  forceps  grasp,  when  the  foreign  body  reaches  the  cords. 
This  is  avoided  by  anchoring  the  foreign  body  against  the  tube 
mouth  as  soon  as  the  foreign  body  is  grasped,  as  shown  in  Fig.  79. 
The  left  index  finger  and  thumb  grasp  the  shaft  of  the  forceps 


clamp  forcetosdntt 
tube  \o^ci\ie.r 

during 
V        Tw    traotior.    Oit -f.'b'cln. 


Left  liai-pc). 


Fig.  79  — Method  of  anchoring  the  foreign  body  against  the  tube  mouth  After 
the  object  has  been  drawn  firmly  against  the  lip  of  the  endoscopic  tube  the  left 
finger  and  thumb  grasp  the  forceps  cannula  and  lock  it  against  the  ocular  end  of  the 
tube,  the  other  fingers  of  the  left  hand  encircle  the  tube.  Withdrawal  is  then  done 
with  the  left  hand;  the  fingers  of  the  right  hand  maintaining  closure  of  the  forceps. 


close  to  the  ocular  end  of  the  tube,  while  the  other  fingers  encircle 
the  tube;  closure  of  the  forceps  is  maintained  by  the  fingers  of  the 
right  hand,  while  all  traction  for  withdrawal  is  made  with  the 
left  hand,  which  firmly  clamps  forceps  and  bronchoscope  as  one 
piece.  Thus  the  three  units  are  brought  out  as  one;  the  broncho- 
scope keeping  the  cords  apart  until  the  foreign  body  has  entered 
the  glottis. 


164  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

Bringing  the  Foreign  Body  Through  the  Glottis. — Stripping  of 
the  foreign  body  from  the  forceps  at  the  glottis  may  be  due  to: 

1.  Not  keeping  the  object  against  the  tube  mouth  as  just 
mentioned. 

2.  Not  bringing  the  greatest  diameter  of  the  foreign  body  into 
the  sagittal  plane  of  the  glottic  chink. 

3.  Faulty  application  of  the  forceps  on  the  foreign  body. 

4.  ^Mechanically  imperfect  forceps. 

Should  the  foreign  body  be  lost  at  the  glottis  it  may,  if  large 
become  impacted  and  threaten  asphyxia.  Prompt  insertion  of 
the  laryngoscope  will  usually  allow  removal  of  the  object  by  means 
of  the  laryngeal  grasping  forceps.  The  object  may  be  dropped  or 
expelled  into  the  pharynx  and  be  swallowed.  It  may  even  be 
coughed  into  the  naso-pharynx  or  it  may  be  re-aspirated. 
In  the  latter  event  the  bronchoscope  is  to  be  re-inserted 
and  the  trachea  carefully  searched.  Care  must  be  used  not  to 
override  the  object.  If  much  inflammatory  reaction  has  occurred 
in  the  first  invaded  bronchus,  temporarily  suspending  the  aerating 
function  of  the  corresponding  lung,  reaspiration  of  a  dislodged 
foreign  body  is  liable  to  carry  it  into  the  opposite  main  bronchus, 
by  reason  of  the  greater  inspiratory  volume  of  air  entering  that 
side.  This  may  produce  sudden  death  by  blocking  the  only  aerat- 
ing organ. 

Extraction  of  Fins,  Needles  and  Similar  Long  Fointed  Objects. — 
When  searching  for  such  objects  especial  care  must  be  taken  not 
to  override  them.  Pins  are  almost  always  found  point  upward, 
and  the  dictum  can  therefore  be  made,  '^Search  not  for  the  pin,  but 
for  the  point  of  the  pin."  If  the  point  be  found  free,  it  should  be 
worked  into  the  lumen  of  the  bronchoscope  by  manipulation  with 
the  lip  of  the  tube.  It  may  then  be  seized  with  the  forceps  and 
withdrawn.  Should  the  pin  be  grasped  by  the  shaft,  it  is  almost 
certain  to  turn  crosswise  of  the  tube  mouth,  where  one  pull  may 


BROXCHOSCOPIC    FOREIGN   BODY    EXTRACTION 


l6: 


cause  the  point  to  perforate,  enormously  increasing  the  difficulties 
by  transfixation,  and  perhaps  resulting  fatally  (Fig.  80). 


0 


Fig.  80.  Fig.  81. 

Fig.  80. — Schematic  illustration  of  a  serious  phase  of  the  error  of  hastily  seizing 
a  transfixed  pin  near  its  middle,  when  first  seen  as  at  M.  Traction  with  the  forceps 
in  the  direction  of  the  dart  in  Schema  B  will  rip  open  the  esophagus  or  bronchus 
inflicting  fatal  trauma,  and  probably  the  pin  will  be  stripped  off  at  the  glottic  or  the 
cricopharyngeal  level,  respectively.  The  point  of  the  pin  must  be  disembedded  and 
gotten  into  the  tube  mouth  as  at  A,  to  make  forceps  traction  safe. 

Fig.  81. ■ — Schema  illustrating  the  mechanical  problem  of  extracting  a  pin,  a 
large  part  of  whose  shaft  is  buried  in  the  bronichial  wall,  B.  The  pin  must  be 
pushed  downward  and  if  the  orifice  of  the  branches,  C,  D,  are  too  small  to  admit 
the  head  of  the  pin  some  other  orifice  (as  at  A)  must  be  found  by  palpation  (not 
by  violent  pushing)  to  admit  the  head,  so  that  the  pin  can  be  pushed  downward 
permitting  the  point  to  emerge  (E).  The  point  is  then  manipulated  into  the 
bronchoscopic  tube-mouth  by  means  of  co-ordinated  movements  of  the  broncho- 
scopic  lip  and  the  side-curved  forceps,  as  shown  at  F. 


Inward  Rotation  Method. — When  the  point  is  found  to  be  buried 
in  the  mucosa,  the  best  and  usually  successful  method  is  to  grasp 
the  pin  as  near  the  point  as  possible  with  the  side-grasping  forceps, 
then  with  a  spiral  motion  to  push  the  pin  downward  while  rotating 
the  forceps  about  ninety  degrees.  The  point  is  thus  disengaged, 
and  the  shaft  of  the  pin  is  brought  parallel  with  that  of  the  forceps, 
after  which  the  point  may  be  drawn  into  the  tube  mouth.     The 


i66 


BRONCHOSCOPY  AND  ESOPHAGOSCOPY 


lips  added  to  the  side-curved  forceps  by  my  assistant  Dr.  Gabriel 
Tucker  I  now  use  exclusively  for  this  inward  rotation  method. 
They  are  invaluable  in  preventing  the  escape  of  the  pin  during  the 
manipulation.     A    hook   is   sometimes   useful   in    disengaging    a 


u" 


/ 


/ 


^ 


A 


^ 


kjN 


^ 


AYl^ 


r> 


D 


Fig.  82  — Mechanical  problem  of  pin,  needle,  tack  or  nail  with  embedded  point. 
If  the  forceps  are  pulled  upon  the  pin  point  will  be  buried  stiU  deeper.  The  side 
curved  forceps  grasp  the  pin  as  near  the  point  as  possible  then  with  a  corkscrew 
motion  the  pin  is  pushed  downward  and  rotated  to  the  right  when  the  pin  will  be 
found  to  be  parallel  with  the  shaft  of  the  forceps  and  can  be  drawn  into  the  tube. 
If  the  pin  is  prevented  by  its  head  from  being  pushed  downward  the  point  may  be 
extracted  by  the  hook  as  shown  above  The  side  curved  forceps  may  be  used  instead 
of  the  hook  for  freeing  the  point,  the  author's  "inward  rotation"  method.  The 
v^ery  best  instrument  for  the  purpose  is  the  forceps  devised  by  my  assistant.  Dr. 
Gabriel  Tucker  (Fig.  21).  The  lips  prevent  all  risk  of  losing  the  pin  from  the 
grasp,  and  at  the  same  time  bring  the  long  axis  of  the  pin  parallel  to  that  of  the 
bronchoscope. 

buried  point.     The  method  of  its  use  is  illustrated  in  Fig.  82. 

Pins  are  very  prone  to  drop  into  the  smaller  bronchi  and  dis- 
appear completely  from  the  ordinary  field  of  endoscopic  explora- 
tion. At  other  times,  pins  not  dropping  so  deeply  may  show  the 
point  only  during  expiration  or  cough,  at  which  times  the  bronchi 
are  shortened.  In  such  instances  the  invaded  bronchial  orifice 
should  be  clearly  exposed  as  near  the  axis  of  its  lumen  as  possible; 


BRONCHOSCOPIC    FOREIGN   BODY    EXTRACTION 


167 


the  forceps  are  now  inserted,  opened,  and  the  next  emergence 
watched  for,  the  point  being  grasped  as  soon  as  seen. 

Extraction  of  Tacks,  Nails  and  Large  Headed  Foreign  Bodies 
from  the  Tracheobronchial  Tree. — In  cases 
of  this  sort  the  point  presents  the  same 
difficulty  and  requires  solution  in  the  same 
manner  as  mentioned  in  the  preceding 
paragraphs  on  the  extraction  of  pins. 
The  author's  inward-rotation  method 
when  executed  with  the  Tucker  forceps 
is  ideal.  The  large  head,  however,  pre- 
sents a  special  problem  because  of  its 
tendency  to  act  as  a  mushroom  anchor 
when  buried  in  swollen  mucosa  or  in  a 
fibrous  stenosis  (Fig.  83).  The  extrac- 
tion problems  of  tacks  are  illustrated  in 
Figs.  84,  85,  and  86.  Nails,  stick  pins, 
and  various  tacks  are  dealt  with  in  the 
same  manner  by  the  author's  "inward 
rotation"  method. 

Hollow  metallic  bodies  presenting  an 
opening  toward  the  observer  may  be 
removed  with  a  grooved  expansile  forceps 
as  shown  in  Figs  23  and  25,  or  its  edge  may 
be  grasped  by  the  regular  side-grasping 
forceps.  The  latter  hold  is  apt  to  be  very 
dangerous  because  of  the  trauma  inflicted 
by  the  catching  of  the  free  edge  opposite 
the  forceps;  but  with  care  it  is  the  best 
method.  Should  the  closed  end  be  upper- 
most, however,  it  may  be  necessary  to  insert  a  hook  beyond  the 
object,  and  to  coax  it  upward  to  a  point  where  it  may  be  turned  for 
grasping  and  removal  with  forceps. 


z 

Fig  83. — "Mushroom 
anchor"  problem  of  the 
upholstery  tack.  If  the 
tack  has  not  been  in  situ 
more  than  a  few  weeks  the 
stenosis  at  the  level  of  the 
darts  is  simply  edematous 
mucosa  and  the  tack  can 
be  pulled  through  with 
no  more  than  slight  muco- 
sal trauma,  provided  axis- 
traction  only  be  used.  If 
the  tack  has  been  in  situ  a 
year  or  more  the  fibrous 
stricture  may  need  dilata- 
tion with  the  divulsor. 
Otherwise  traction  may 
rupture  the  bronchial  wall. 
The  stenotic  tissue  in  cases 
of  a  few  months'  sojourn 
may  be  composed  of  granu- 
lations, in  which  case  axis- 
traction  will  safely  with- 
draw it.  The  point  of  a 
tack  rarely  projects  freely 
into  the  lumen  as  here 
shown.  More  often  it  is 
buried  in  the  wall. 


i68 


BRONCHOSCOPY  AND  ESOPHAGOSCOPY 


Fig.  84. — Schema  illustrating  the  "mushroom  anchor"  problem  of  the  brass 
headed  upholstery  tack  At  A  the  tack  is  shown  with  the  head  bedded  in  swollen 
mucosa.  The  bronchoscopist,  looking  through  the  bronchoscope,  E,  considering 
himself  lucky  to  have  found  the  point  of  the  tack,  seizes  it  and  starts  to  with- 
draw it,  making  traction  as  shown  by  the  dart  in  drawing  B.  The  head  of 
the  tack  catches  below  a  chondrial  ring  and  rips  in,  tearing  its  way  through  the 
bronchial  wall  (D)  causing  death  by  mediastinal  emphysema.  This  accident  is 
still  more  likely  to  occur  if,  as  often  happens,  the  tack-head  is  lodged  in  the  orifice 
of  the  upper  lobe  bronchus^  F.  But  if  the  bronchoscopist  swings  the  patient's  head 
far  to  the  opposite  side  and  makes  axis-traction,  as  shown  at  C,  the  head  of  the  tack 
can  be  drawn  through  the  swollen  mucosa  without  anchoring  itself  in  a  cartilage. 
If  necessary,  in  addition,  the  Up  of  the  bronchoscope  can  be  used  to  repress  the  angle, 
K,  and  the  swollen  mucosa,  H.  If  the  swollen  mucosa,  H,  has  been  replaced  by 
fibrous  tissue  from  many  months'  sojourn  of  the  tack,  the  stenosis  may  require 
dilatation  with  the  divulsor. 


Fig.  85. — Problem  of  the  upholstery  tack  with  buried  point.  If  pulled  upon, 
the  imminent  perforation  of  the  mediastinum,  as  shown  at  A.  will  be  completed, 
the  bronchus  wiU  be  torn  and  death  will  follow  even  if  the  tack  be  removed,  which  is 
of  doubtful  possibility,  The  proper  method  is  gently  to  close  the  side  curved  forceps 
on  the  shank  of  the  tack  near  the  head,  push  downward  as  shown  by  the  dart,  in  B, 
until  the  point  emerges.  Then  the  forceps  are  rotated  to  bring  the  point  of  the  tack 
away  from  the  bronchial  wall. 


BEONCHOSCOPIC    FOREIGN   BODY    EXTRACTION 


169 


Removal  of  Open  Safety  Pins  from  the  Trachea  and  Bronchi. — 
Removal  of  a  closed  safety  pin  presents  no  difficulty  if  it  is  grasped 
at  one  or  the  other  end.  A  grasp  in  the  middle  produces  a  ''toggle 
and  ring"  action  which  would  prevent  extraction.  When  the 
safety  pin  is  open  with  the  point  downward  care  must  be  exercised 


Fig.  86. — Schema  illustrating  the  "upper-lobe-bronchus  problem,"  combined 
with  the  "mushroom-anchor"  problem  and  the  author's  method  for  their  solution. 
The  patient  being  recumbent,  the  bronchoscopist  looking  down  the  right  main 
bronchus,  M,  sees  the  point  of  the  tack  projecting  from  the  right  upper-lobe-bron- 
chus, A.  He  seizes  the  point  with  the  side-curved  forceps;  then  slides  down  the 
bronchoscope  to  the  position  shown  dotted  at  B.  Next  he  pushes  the  bronchoscopic 
tube-mouth  downward  and  medianward,  simultaneously  moving  the  patient's  head 
to  the  right,  thus  swinging  the  bronchoscopic  level  on  its  fulcrum,  and  dragging  the 
tack  downward  and  inward  out  of  its  bed,  to  the  position,  D.  Traction,  as  shown 
at  C,  will  then  safely  and  easily  withdraw  the  tack.  A  very  small  bronchoscope  is 
essential.  The  lip  of  the  bronchoscopic  tube-mouth  must  be  used  to  pry  the  forceps 
down  and  over,  and  the  lip  must  be  brought  close  to  the  tack  just  before  the  prying- 
pushing  movement.     S,  right  stem-bronchus. 


not  to  override  it  with  the  bronchoscope  or  to  push  the  point 
through  the  wall.  The  spring  or  near  end  is  to  be  grasped  with  the 
side-curved  or  the  rotation  forceps  (Figs.  19,  20  and  31)  and  pulled 
into  the  bronchoscope,  thus  closing  the  pin.  An  open  safety  pin 
lodged  point  up  presents  an  entirely  different  and  a  very  difficult 
problem.  If  traction  is  made  without  closing  the  pin  or  protecting 
the  point  severe  and  probably  fatal  trauma  will  be  produced. 
The  pin  may  be  closed  with  the  pin-closer  as  illustrated  in  Fig.  37, 


lyo 


BRONCHOSCOPY  AND  ESOPHAGOSCOPY 


and  then  removed  with  forceps.  Arrowsmith's  pin-closer  is 
excellent.  Another  method  (Fig.  87)  consists  in  bringing  the 
point  of  the  safety  pin  into  the  bronchoscope,  after  disengaging 
the  point  with  the  side  curved  forceps,  by  the  author's  "inward 
rotation"  method.  The  forceps-jaws  (Fig.  21)  devised  recently 
by  my  assistant,  Dr.  Gabriel  Tucker,  are  ideal  for  this  maneuver. 

As  the  point  is  now  protected, 
the  spring,  seen  just  off  the  tube 
mouth,  is  best  grasped  with  the 
rotation  forceps,  which  afford  the 
securest  hold.  The  keeper  and 
its  shaft  are  outside  the  broncho- 
scope, but  its  rounded  portion  is 
uppermost  and  will  glide  over  the 
tissues  without  trauma  upon  care- 
ful withdrawal  of  the  tube  and 
safety  pin.  Care  must  be  taken 
to  rotate  the  pin  so  that  it  lies 
in  the  sagittal  plane  of  the  glot- 
tis with  the  keeper  placed  poste- 
riorly, for  the  reason  that  the  base  of  the  glottic  triangle  is  posterior, 
and  that  the  posterior  wall  of  the  larynx  is  membranous  above  the 
cricoid  cartilage,  and  will  yield.  A  small  safety-pin  may  be 
removed  by  version,  the  point  being  turned  into  a  branch  bronchial 
orifice.  No  one  should  think  of  attempting  the  extraction  of  a 
safety  pin  lodged  point  upward  without  having  practiced  for  at 
least  a  hundred  hours  on  the  rubber  tube  manikin.  This  practice 
should  be  carried  out  by  anyone  expecting  to  do  endoscopy, 
because  it  affords  excellent  education  of  the  eye  and  the  fingers  in 
the  endoscopic  manipulation  of  any  kind  of  foreign  body.  Then, 
when  a  safety  pin  case  is  encountered,  the  bronchoscopist  will  be 
prepared  to  cope  with  its  difficulties,  and  he  will  be  able  to  deter- 


FiG.  87. — One  method  of  dealing 
with  an  open  safety  pin  without 
closing  it. 


BRONCHOSCOPIC    FOREIGN   BODY    EXTRACTION 


171 


mine  which  of  the  methods  will  be  best  suited  to  his  personal 
equation  in  the  particular  case. 

Removal  of  Double  Pointed  Tacks. — If  the  tack  or  staple  be 
small,  and  lodged  in  a  relatively  large  trachea  a  version  may  be 
done.  That  is,  the  staple  may  be  turned  over  with  the  hook  or 
rotation  forceps  and  brought  out  with  the  points  trailing.     With 


Fig.  88. — Schema  illustrating  podalic  version  of  bronchially-Iodged  staples  or 
double-pointed  tacks.  IT,  bronchoscope.  .\,  swollen  mucosa  covering  points  of 
staple.  At  E  the  staple  has  been  manipulated  upward  with  bronchoscopic  lip  and 
hooks  until  the  points  are  opposite  the  branch  bronchial  orifices,  B,  C.  Traction 
being  made  in  the  direction  of  the  dart  (F),  by  means  of  the  rotation  forceps,  and 
counterpressure  being  m.ade  with  the  bronchoscopic  lip  on  the  points  of  the  staple,  the 
points  enter  the  branch  bronchi  and  permit  the  staple  to  be  turned  over  and  removed 
with  points  trailing  harmlessly  behind  (K). 

a  long  staple  in  a  child's  trachea  the  best  method  is  to  "coax" 
the  intruder  along  gently  under  ocular  guidance,  never  making 
traction  enough  to  bury  the  point  deeply,  and  lifting  the  point 
with  the  hook  whenever  it  shows  any  inclination  to  enter  the 
wall.  Great  care  and  dexterity  are  required  to  get  the  intruder 
through  the  glottis.  In  certain  locations,  one  or  both  points  may 
be  turned  into  branch  bronchi  as  illustrated  in  Fig.  88,  or  over 
the  carina  into  the  opposite  main  bronchus.  Another  method  is 
to  get  both  points  into  the  tube-mouth.     This  may  be  favored, 


172 


BRONCHOSCOPY  AND  ESOPHAGOSCOPY 


as  demonstrated  by  my  assistant,  Dr.  Gabriel  Tucker,  by  tilting 
the  staple  so  as  to  get  both  points  into  the  longest  diameter  of 
the  tube-mouth.  In  some  cases  I  have  squeezed  the  broncho- 
scope in  a  vise  to  create  an  oval  tube-mouth.  In  other  cases 
I  have  used  expanding  forceps  with  grooved  blades. 

The  Extraction  of  Tightly  Fitting  Foreign  Bodies  from  the 
Bronchi.  Annular  Edema. — Such  objects  as  marbles,  pebbles, 
corks,  etc.,  are  drawn  deeply  and  with  force  by  the  inspiratory 


Fig.  89. — Schema  illustrating  the  use  of  the  lip  of  the  bronchoscope  in  disimpac- 
tion  of  foreign  bodies.  A  and  B  show  an  annular  edema  above  the  foreign  body,  F. 
At  C  the  edematous  mucosa  is  being  repressed  by  the  lip  of  the  tube  mouth,  permit- 
ting insinuation  of  the  hook,  H,  past  one  side  of  the  foreign  body,  which  is  then  with- 
drawn to  a  convenient  place  for  application  of  the  forceps.  This  repression  by  the 
lip  is  often  used  for  purposes  other  than  the  insertion  of  hooks.  The  lip  of  the  eso- 
phagoscope  can  be  used  in  the  same  way. 

blast  into  the  smallest  bronchus  they  can  enter.  The  air  distal 
to  the  impacted  foreign  body  is  soon  absorbed,  and  the  negative 
pressure  thus  produced  increases  the  impaction.  A  ring  of 
edematous  mucosa  quickly  forms  and  covers  the  presenting  part 
of  the  object,  leaving  visible  only  a  small  surface  in  the  center  of 
an  acute  edematous  stenosis.  A  forceps  with  narrow,  stiff, 
expansive-spring  jaws  may  press  back  a  portion  of  the  edema  and 
may  allow  a  grasp  on  the  sides  of  the  foreign  body;  but  usually 
the  attempt  to  apply  forceps  when  there  are  no  spaces  between 
the  presenting  part  of  the  foreign  body  and  the  bronchial  wall, 
will  result  only  in  pushing  the  foreign  body  deeper.*  A  better 
*  The  author's  new  ball  forceps  are  very  successful  with  ball-bearing  balls  and 
marbles. 


BRONCHOSCOPIC    FOREIGN   BODY    EXTRACTION  1 73 

method  is  to  use  the  lip  of  the  bronchoscope  to  press  back  the 
swollen  mucosa  at  one  point,  so  that  a  hook  may  be  introduced 
below  the  foreign  body,  which  then  can  be  worked  up  to  a  wider 
place  where  forceps  may  be  applied  (Fig.  89).  Sometimes  the 
object  may  even  be  held  firmly  against  the  tube  mouth  with  the 
hook  and  thus  extracted.  For  this  the  unslanted  tube-mouth  is 
used. 

Extraction  of  Soft  Friable  Foreign  Bodies  from  the  Tracheo- 
bronchial Tree. — The  difficulties  here  consist  in  the  liability  of 
crushing  or  fragmenting  the  object,  and  scattering  portions  into 
minute  bronchi,  as  well  as  the  problem  of  disimpaction  from  a  ring 
of  annular  edema,  with  little  or  no  forceps  space.  There  is 
usually  in  these  cases  an  abundance  of  purulent  secretion  which 
further  hinders  the  work.  The  great  danger  of  pushing  the  foreign 
body  downward  so  that  the  swollen  mucosa  hides  it  completely 
from  view,  must  always  be  kept  in  mind.  Extremely  delicate 
forceps  with  rather  broad  blades  are  required  for  this  work. 
The  fenestrated  "peanut"  forceps  are  best  for  large  pieces  in  the 
large  bronchi.  The  operator  should  develop  his  tactile  sense  with 
forceps  by  repeated  practice  in  order  to  acquire  the  skill  to 
grasp  peanut  kernels  sufficiently  firmly  to  hold  them  during  with- 
drawal, yet  not  so  firmly  as  to  crush  them.  Nipping  off  an  edge 
by  not  inserting  the  forceps  far  enough  is  also  to  be  avoided. 
Small  fragments  under  2  mm.  in  diameter  may  be  expelled  with 
the  secretions  and  fragments  may  be  found  on  the  sponges  and  in 
the  secretions  aspirated  or  removed  by  sponge  pumping.  It  is, 
however,  never  justifiable  deliberately  to  break  a  friable  foreign 
body  with  the  hope  that  the  fragments  will  be  expelled,  for  these 
may  be  aspirated  into  small  bronchi,  and  cause  multiple  abscesses. 
A  hook  may  be  found  useful  in  dealing  with  round,  friable,  foreign 
bodies;  and  in  some  cases  the  mechanical  spoon  or  safety-pin 
closer  may  be  used  to  advantage.  The  foreign  body  is  then 
brought  close  to,  but  not  crushed  against  the  tube  mouth. 


174 


BRONCHOSCOPY  AND  ESOPHAGOSCOPY 


Removal  of  animal  objects  from  the  tracheobronchial  tree  is 
readily  accomplished  with  the  side-curved  forceps.  Leeches  are 
not  uncommon  intruders  in  European  countries.  Small  insects 
are  usually  coughed  out.  Worms  and  larvae  may  be  found. 
Cocaine  or  salt  solution  will  cause  a  leech  to  loosen  its  hold. 
Foreign  bodies  in  the  upper-lobe  bronchi  are  fortunately  not 

common.  If  the  object  is  not 
too  far  out  to  the  periphery  it 
may  be  grasped  by  the  upper- 
lobe-bronchus  forceps  (Fig.  90), 
guided  by  the  collaboration  of 
the  fluoroscopist.  These  for- 
ceps are  made  so  as  to  reach 
high  into  the  ascending  branches 
of  the  upper-lobe  bronchus. 
Full -curved  coil-spring  hooks 
will  reach  high,  but  must  be 
used  with  the  utmost  caution, 
and  the  method  of  their  disen- 


FiG.  90. — Schematic  illustration  of 
the  author's  upper-lobe-bronchus  for- 
ceps in  position  grasping  a  pin  in  an 
anteriorly  ascending  branch  of  the  upper- 
lobe  bronchus.    T,  Trachea;  UL,  upper-     gagement    must    be    practiced 

lobe   bronchus;  LB,  left  bronchus;  SB,      ,     .       u       j 
stem  bronchus.     These  forceps  are  made 

to  extend  around  180  degrees.  Penetrating  Projectiles. — 

Foreign  bodies  that  have  pene- 
trated the  chest  wall  and  lodged  in  the  lung  may  be  removed 
by  oral  bronchoscopy  if  the  intruder  is  not  larger  than  the  lumen 
of  the  corresponding  main  bronchus  (see  Bibliography,  43) . 


RULES  FOR  ENDOSCOPIC  FOREIGN  BODY  EXTRACTION 

1.  Never  endoscope  a  foreign  body  case  unprepared,  with  the 
idea  of  taking  a  preliminary  look. 

2.  Approach   carefully   the   suspected   location   of  a   foreign 
body,  so  as  not  to  override  any  portion  of  it. 


BRONCHOSCOPIC    FOREIGN   BODY    EXTRACTION  1 75 

3.  Avoid  grasping  a  foreign  body  hastily  as  soon  as  seen. 

4.  The  shape,  size  and  position  of  a  foreign  body,  and  its  rela- 
tions to  surrounding  structures,  should  be  studied  before  attempt- 
ing to  apply  the  forceps.     (Exception  cited  in  Rule  lo.) 

5.  Preliminary  study  of  a  foreign  body  should  be  from  a 
distance. 

6.  As  the  first  grasp  of  the  forceps  is  the  best,  it  should  be  well 
planned  beforehand  so  as  to  seize  the  proper  part  of  the  intruder. 

7.  With  all  long  foreign  bodies  the  motto  should  be  "Search, 
not  for  the  foreign  body,  but  for  its  nearer  end."  With  pins, 
needles,  and  the  like,  with  point  upward,  search  always  for  the 
point.     Try  to  see  it  first. 

8.  Remember  that  a  long  foreign  body  grasped  near  the  middle 
becomes,  mechanically  speaking,  a  "toggle  and  ring." 

9.  Remember  that  the  mortality  to  follow  failure  to  remove  a 
foreign  body  does  not  justify  probably  fatal  violence  during  its 
removal. 

10.  Laryngeally  lodged  foreign  bodies,  because  of  the  likeli- 
hood of  dislodgment  and  loss,  may  be  seized  by  any  part  first 
presented,  and  plan  of  withdrawal  can  be  determined  afterward. 

11.  For  similar  reasons,  laryngeal  cases  should  be  dealt  with 
only  in  the  author's  position  (Fig.  53). 

12.  An  esophagoscopy  may  be  needed  in  a  bronchoscopic 
case,  or  a  bronchoscopy  in  an  esophageal  case.  In  every  case 
both  kinds  of  tubes  should  be  sterile  and  ready  before  starting. 
It  is  the  unexpected  that  happens  in  foreign  body  endoscopy. 

13.  Do  not  pull  on  a  foreign  body  unless  it  is  properly  grasped 
to  come  away  readily  without  trauma.     Then  do  not  pull  hard. 

14.  Do  no  harm,  if  you  cannot  remove  the  foreign  body. 

15.  Full-curved  hooks  are  to  be  used  in  the  bronchi  with  great- 
est caution,  if  used  at  all,  lest  they  catch  inextricably  in  branch 
bronchi. 


176  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

16.  Don't  force  a  foreign  body  downward.  Coax  it  back. 
The  deeper  it  gets  the  greater  your  difl&culties. 

17.  The  watchword  of  the  bronchoscopist  should  be,  "If  I 
can  do  no  good,  I  will  at  least  do  no  harm." 

Fluoroscopic  bronchoscopy  is  so  deceptively  easy  from  a  super- 
ficial, theoretical,  point  of  view  that  it  has  been  used  unsuccessfully 
in  cases  easily  handled  in  the  regular  endoscopic  way  with  the 
eye  at  the  proximal  tube-mouth.  In  a  collected  series  of  cases 
by  various  operators  the  object  was  removed  in  66.7  per  cent  with 
a  mortality  of  41.6  per  cent.  In  the  problem  of  a  pin  located  out 
of  the  field  of  bronchoscopic  vision,  the  fluoroscopist  will  yield 
invaluable  aid.  An  extremely  delicate  forceps  is  to  be  inserted 
closed  into  the  invaded  bronchus,  the  grasp  on  the  object  being 
confirmed  by  the  fluoroscopist.  It  is  to  be  kept  in  mind  that  while 
the  object  itself  may  be  in  the  grasp  of  the  forceps,  the  fluoroscope 
will  not  show  whether  there  may  not  be  included  in  the  forceps' 
grasp  a  bronchial  spur  or  other  tissue,  the  tearing  of  which  may  be 
fatal.  Therefore  traction  must  not  be  sufficient  to  lacerate  tissue. 
If  the  foreign  body  does  not  come  readily  it  must  be  released,  and 
a  new  grasp  may  then  be  taken.  All  of  the  cautions  in  faulty 
seizure  already  mentioned,  apply  with  particular  force  to  fluoro- 
scopic bronchoscopy.  The  fluoroscope  is  of  aid  in  finding  foreign 
bodies  held  in  abscess  cavities.  The  fluoroscope  should  show  both 
the  lateral  and  anteroposterior  planes.  To  accomplish  this 
quickly,  two  Coolidge  tubes  and  two  screens  are  necessary.  Fluo- 
roscopic bronchoscopy,  because  of  its  high  mortality  and  low 
percentage  of  successes,  should  be  tried  only  after  regular,  ocularly 
guided,  peroral  bronchoscopy  has  failed,  and  only  by  those  who 
have  had  experience  in  ocularly  guided  bronchoscopy. 


CHAPTER  XVI 

FOREIGN   BODIES   IN   THE   BRONCHI   FOR  PROLONGED 

PERIODS 

The  sojourn  of  an  inorganic  foreign  body  in  the  bronchus  for 
a  year  or  more  is  followed  by  the  development  of  bronchiectasis, 
pulmonary  abscess,  and  fibrous  changes.  The  symptoms  of 
tuberculosis  may  all  be  presented,  but  tubercle  bacilli  have  never 
been  found  associated  with  any  of  the  many  cases  that  have  come 
to  the  Bronchoscopic  Clinic*  The  history  of  repeated  attacks  of 
malaise,  fever,  chills,  and  sweats  lasting  for  a  few  days  and  termi- 
nated by  the  expulsion  of  an  amount  of  foul  pus,  suggests  the  inter- 
mittent drainage  of  an  abscess  cavity,  and  special  study  should 
be  made  to  eliminate  foreign  body  as  the  cause  of  the  condition, 
in  all  such  cases,  whether  there  is  any  history  of  a  foreign  body 
accident  or  not.  Bronchoscopy  for  diagnosis  is  to  be  done  unless 
the  etiology  can  be  definitely  proven  by  other  means.  In  all 
cases  of  chronic  chest  disease  foreign  body  should  be  eliminated 
as  a  matter  of  routine. 

The  time  of  aspiration  of  a  foreign  body  may  be  unknown,  having 
possibly  occurred  in  infancy,  during  narcosis,  or  the  object  may 
even  enter  the  lower  air  passages  without  the  patient  being  aware 
of  the  accident,  as  happened  with  a  particularly  inteUigent  business 
man  who  unknowingly  aspirated  the  tip  of  an  atomizer  while 
spraying  his  throat.  In  many  other  cases  the  accident  had  been 
forgotten.  In  still  others,  in  spite  of  the  patient's  statement  of  a 
conviction  that  the  trouble  was  due  to  a  foreign  body  he  had  aspi- 
rated, the  physician  did  not  consider  it  worthy  of  sufficient  consid- 
eration  to   warrant  a  roentgenray   examination.     It  is   curious 

*  One  exception  has  recently  come  to  the  Clinic. 
12  177 


lyS  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

to  note  the  various  opinions  held  in  regard  to  the  gravity  of  the 
presence  of  a  bronchial  foreign  body.  One  patient  was  told  by 
his  physician  that  the  presence  of  a  staple  in  his  bronchus  was  an 
impossibility,  for  he  would  not  have  lived  five  minutes  after  the 
accident.  Others  consider  the  presence  of  a  foreign  body  in  the 
bronchus  as  comparatively  harmless,  in  spite  of  the  repeated 
reports  of  invalidism  and  fatality  in  the  medical  literature  of 
centuries.  The  older  authorities  state  that  all  cases  of  prolonged 
bronchial  foreign  body  sojourn  died  from  phthisis  pulmonalis,  and 
it  is  still  the  opinion  of  some  practitioners  that  the  presence  of  a 
foreign  body  in  the  lung  predisposes  to  the  development  of  true 
tuberculosis.  With  the  dissemination  of  knowledge  regarding  the 
possibility  of  bronchial  foreign  body,  and  the  marvellous  success  in 
their  removal  by  bronchoscopy,  the  cases  of  prolonged  foreign  body 
sojourn  should  decrease  in  number.  It  should  be  the  recognized 
rule,  and  not  the  exception,  that  all  chest  conditions,  acute  or 
chronic,  should  have  the  benefit  of  roentgenographic  study,  even 
apart  from  the  possibility  of  foreign  body. 

Often  even  with  the  clear  history  of  foreign-body  aspiration, 
both  patient  and  physician  are  deluded  by  a  relatively  long  period 
of  quiescence  in  which  no  symptoms  are  apparent.  This  symp- 
tomless interval  is  followed  sooner  or  later  by  ever  increasing 
cough  and  expectoration  of  sputum,  finally  by  bronchiectasis  and 
pulmonary  abscess,  chronic  sepsis,  and  invalidism. 

Pathology. — If  the  foreign  body  completely  obstructs  a  main 
bronchus,  preventing  both  aeration  and  drainage,  such  rapid 
destruction  of  lung  tissue  follows  that  extensive  pathologic  changes 
may  result  in  a  few  months,  or  even  in  a  few  weeks,  in  the  case  of 
irritating  foreign  bodies  such  as  peanut  kernels  and  soft  rubber. 
Very  minute,  inorganic  foreign  bodies  may  become  encysted  as  in 
anthracosis.  Large  objects,  however,  do  not  become  encysted. 
The  object  is  drawn  down  by  gravity  and  aspirated  into  the  small- 


FOREIGN   BODIES    IN    THE    BRONCHI  1 79 

est  bronchus  it  can  enter.  Later  the  negative  pressure  below  from 
absorption  of  air  impacts  it  still  further.  Swelling  of  the  bronchial 
mucosa  from  irritation  plus  infection  completes  the  occlusion  of  the 
bronchus.  Retention  of  secretions  and  bacterial  decomposition 
thereof  produces  first  a  "drowned  lung"  (natural  passages  full 
of  pus);  then  sloughing  or  ulceration  in  the  tissues  plus  the 
pressure  of  the  pus,  causes  bronchiectasis;  further  destruction 
of  the  cartilaginous  rings  results  in  true  abscess  formation  below 
the  foreign  body.  The  productive  inflammation  at  the  site  of 
lodgement  of  the  foreign  body  results  in  cicatricial  contraction 
and  the  formation  of  a  stricture  at  the  top  of  the  cavity,  in  which 
the  foreign  body  is  usually  held.  The  abscess  may  extend  to  the 
periphery  and  rupture  into  the  pleural  cavity.  It  may  drain 
intermittently  into  a  bronchus.  Certain  irritating  foreign  bodies, 
such  as  soft  rubber,  may  produce  gangrenous  bronchitis  and 
multiple  abscesses.  For  observations  on  pathology  (see  Bib- 
liography, 38). 

Prognosis. — If  the  foreign  body  be  not  removed,  the  resulting 
chronic  sepsis  or  pulmonary  hemorrhage  will  prove  fatal.  Re- 
moval of  the  foreign  body  usually  results  in  complete  recovery 
without  further  local  treatment.  Occasionally,  secondary  dilata- 
tion of  a  bronchial  stricture  may  be  required.  All  cases  will  need, 
besides  removal  of  the  foreign  body,  an  antituberculous  regimen, 
and  offer  a  good  prognosis  if  this  be  followed. 

Treatment. — Bronchoscopy  should  be  done  in  all  cases  of 
chronic  pulmonary  abscess  and  bronchiectasis  even  though  radio- 
graphic study  reveals  no  shadow  of  foreign  body.  The  patient 
by  assuming  a  posture  with  the  head  lowered  is  urged  to  expel 
spontaneously  all  the  pus  possible,  before  the  bronchoscopy. 
The  aspirating  bronchoscope  (Fig.  2,  E)  is  often  useful  in  cases 
where  large  amounts  of  secretion  may  be  anticipated.  Granula- 
tions may  require  removal  with  forceps  and  sponging.     Disturbed 


l8o  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

granulations  result  in  bleeding  which  further  hampers  the  opera- 
tion; therefore,  they  should  not  be  touched  until  ready  to  apply 
the  forceps,  unless  it  is  impossible  to  study  the  presentation  with- 
out disturbing  them.  For  this  reason  secretions  hiding  a  foreign 
body  should  be  removed  with  the  aspirating  tube  (Fig.  9)  rather 
than  by  swabbing  or  sponge-pumping,  when  the  bronchoscopic 
tube-mouth  is  close  to  the  foreign  body.  It  is  inadvisable,  how- 
ever, to  insert  a  forceps  into  a  mass  of  granulations  to  grope 
blindly  for  a  foreign  body,  with  no  knowledge  of  the  presentation, 
the  forceps  spaces,  or  the  location  of  branch-bronchial  orifices 
into  which  one  blade  of  the  forceps  may  go.  Dilatation  of  a 
stricture  may  be  necessary,  and  may  be  accomplished  by  the  forms 
of  bronchial  dilators  shown  in  Fig.  25.  The  hollow  type  of  dilator 
is  to  be  used  in  cases  in  which  the  foreign  body  is  held  in  the  stric- 
ture (Fig.  83).  This  dilator  may  be  pushed  down  over  the  stem 
of  such  an  object  as  a  tack,  and  the  stricture  dilated  without  the 
risk  of  pushing  the  object  downward.  It  is  only  rarely,  however, 
that  the  point  of  a  tack  is  free.  Dense  cicatricial  tissue  may 
require  incision  or  excision.  Internal  bronchotomy  is  doubtless, 
a  very  dangerous  procedure,  though  no  fatalities  have  occurred 
in  any  of  the  three  cases  in  the  Bronchoscopic  Clinic.  It  is  advis- 
able only  as  a  last  resort. 


CHAPTER  XVII 
UNSUCCESSFUL  BRONCHOSCOPY  FOR  FOREIGN  BODIES 

The  limitations  of  bronchoscopic  removal  of  foreign  bodies 
are  usually  manifested  in  the  failure  to  find  a  small  foreign  body 
which  has  entered  a  minute  bronchus  far  down  and  out  toward  the 
periphery.  When  localization  by  means  of  transparent  films, 
fluoroscopy,  and  endobronchial  bismuth  insufflation  has  failed, 
the  question  arises  as  to  the  advisability  of  endoscopic  excision 
of  the  tissue  intervening  between  the  foreign  body  and  broncho- 
scope with  the  aid  of  two  fiuoroscopes,  one  for  the  lateral  and  the 
other  the  vertical  plane.  With  foreign  bodies  in  the  larger  bronchi 
near  the  root  of  the  lung  such  a  procedure  is  unnecessary,  and 
injury  to  a  large  vessel  would  be  almost  certain.  At  the  extreme 
periphery  of  the  lung  the  danger  is  less,  for  the  vessels  are  smaller 
and  serious  hemorrhage  less  probable,  through  the  retention  and 
decomposition  of  blood  in  small  bronchi  with  later  abscess  forma- 
tion is  a  contingency.  The  nature  of  the  bridge  of  tissue  is  to  be 
considered;  should  it  be  cicatricial,  the  result  of  prolonged  inflam- 
matory processes,  it  may  be  carefully  excised  without  very  great 
risk  of  serious  complications.  The  blood  vessels  are  diminished 
in  size  and  number  by  the  chronic  productive  inflammation, 
which  more  than  offsets  their  lessened  contractility. 

The  possibility  of  the  foreign  body  being  coughed  out  after 
suppurative  processes  have  loosened  its  impaction  is  too  remote; 
and  the  lesions  established  may  result  fatally  even  after  the  expul- 
sion of  the  object.  Pulmonary  abscess  formation  and  rupture 
into  the  pleura  should  not  be  awaited,  for  the  foreign  body  does 
not  often  follow  the  pus  into  the  pleural  cavity.     It  remains  in 


1 82  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

the  lung,  held  in  a  bed  of  granulation  tissue.  Furthermore,  to 
await  the  development  is  to  subject  the  patient  to  a  prolonged  and 
perhaps  fatal  sepsis,  or  a  fatal  pulmonary  hemorrhage  from  the 
erosion  of  a  vessel  by  the  suppurative  process.  The  recent  develop- 
ments in  thoracic  surgery  have  greatly  decreased  the  operative 
mortality  of  thoracotomy,  so  that  this  operation  is  to  be  con- 
sidered when  bronchoscopy  has  failed.  Bronchoscopy  can  be 
considered  as  having  failed,  for  the  time  being,  when  two  or  more 
expert  bronchoscopists  on  repeated  search  have  been  unable  to 
find  the  foreign  body  or  to  disentangle  it;  but  the  art  of  broncho- 
scopy is  developing  so  rapidly  that  the  failures  of  a  few  years 
ago  would  be  easy  successes  today.  Before  considering  thoracot- 
omy months  of  study  of  the  mechanical  problem  are  advisable. 
It  is  probable  that  any  foreign  body  of  appreciable  size  that  has 
gone  down  the  natural  passages  can  be  brought  back  the  same 
way. 

In  the  event  of  a  foreign  body  reaching  the  pleura,  either  with 
or  without  pus,  it  should  be  removed  immediately  by  pleuroscopy 
or  by  thoracotomy,  without  waiting  for  adhesive  pleuritis. 

The  problem  may  be  summarized  thus: 

1.  Large  foreign  bodies  in  the  trachea  or  large  bronchi  can 
always  be  removed  by  bronchoscopy. 

2.  The  development  of  bronchoscopy  having  subsequently 
solved  the  problems  presented  by  previous  failures,  it  seems  prob- 
able that  by  patient  developmental  endeavor,  any  foreign  body  of 
appreciable  size  that  has  gone  down  through  the  natural  passages, 
can  be  bronchoscopically  removed  the  same  way,  provided  fatal 
trauma  is  avoided. 

At  the  author's  Bronchoscopic  Clinics  98.7  per  cent  of  foreign 
bodies  have  been  removed. 


CHAPTER  XVIII 
FOREIGN  BODIES  IN  THE  ESOPHAGUS 

Etiology. — The  lodgement  of  foreign  bodies  in  the  esophagus 
is  influenced  by: 

1.  The  shape  of  the  foreign  body  (disc-shaped,  pointed,  irregu- 
lar). 

2.  Resiliency  of  the  object  (safety  pins). 

3.  The  size  of  the  foreign  body. 

4.  Narrowing  of  the  esophagus,  spasmodic  or  organic,  normal, 
or  pathologic. 

5.  Paralysis  of  the  normal  esophageal  propulsory  mechanism. 
The  lodgement  of  a  bolus  of  ordinary  food  in  the  esophagus 

is  strongly  suggestive  of  a  preexisting  narrowing  of  the  lumen  of 
either  a  spasmodic  or  organic  nature;  a  large  bolus  of  food,  poorly 
masticated  and  hurriedly  swallowed,  may,  however,  become 
impacted  in  a  perfectly  normal  esophagus. 

Carelessness  is  the  cause  of  over  80  per  cent  of  the  foreign 
bodies  in  the  esophagus  (see  Bibliography,  29). 

Site  of  Lodgement. — Almost  all  foreign  bodies  are  arrested  in 
the  cervical  esophagus  at  the  level  of  the  superior  aperture  of  the 
thorax.  A  physiologic  narrowing  is  present  at  this  level,  produced 
in  part  by  muscular  contraction,  and  mainly  by  the  crowding  of 
the  adjacent  viscera  into  the  fixed  and  narrow  upper  thoracic 
aperture.  If  dislodged  from  this  position  the  foreign  body 
usually  passes  downward  to  be  arrested  at  the  next  narrowing  or 
to  pass  into  the  stomach.  The  esophagoscopist  who  encounters 
the  difficulty  of  introduction  at  the  cricopharyngeal  fold  expects 
to  find  the  foreign  body  above  the  fold.     Such,  however,  is  almost 

183 


184  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

never  the  case.  The  cricopharyngeus  muscle  functionates  in 
starting  the  foreign  body  downward  as  if  it  were  food;  but  the 
narrowing  at  the  upper  thoracic  aperture  arrests  it  because  the 
esophageal  peristaltic  musculature  is  feeble  as  compared  to  the 
powerful  inferior  constrictor. 

Symptoms.— Dysphagia  is  the  most  frequent  complaint  in  cases 
of  esophageally  lodged  foreign  bodies.  A  very  small  object  may 
excite  sufficient  spasm  to  cause  aphagia,  while  a  relatively  large 
foreign  body  may  be  tolerated,  after  a  time,  so  that  the  swallowing 
function  may  seem  normal.  Intermittent  dysphagia  suggests 
the  tilting  or  shifting  of  a  foreign  body  in  a  valve-like  fashion; 
but  may  be  due  to  occlusion  of  the  by-passages  by  food  arrested 
by  the  foreign  body.  Dyspnea  may  be  present  if  the  foreign  body 
is  large  enough  to  compress  the  trachea.  Cough  may  be  excited 
by  reflex  irritation,  overflow  of  secretions  into  the  larynx,  or  by 
perforation  of  the  posterior  tracheal  wall,  traumatic  or  ulcerative, 
allowing  leakage  of  food  or  secretion  into  the  trachea.  (See 
Chapter  XII  for  discussion  of  symptomatology  and  diagnosis.) 

Prognosis. — A  foreign  body  lodged  in  the  esophagus  may  prove 
quickly  fatal  from  hemorrhage  due  to  perforation  of  a  large  vessel ; 
from  asphyxia  by  pressure  on  the  trachea;  or  from  perforation 
and  septic  mediastinitis .  Slower  fatalities  may  result  from  suppu- 
ration extending  to  the  trachea  or  bronchi  with  consequent  edema 
and  asphyxia.  Sooner  or  later,  if  not  removed,  the  foreign  body 
causes  death.  It  may  be  tolerated  for  a  long  period  of  time, 
causing  abscess,  cervical  cellulitis,  fistulous  tracts,  and  ultimately 
extreme  stenosis  from  cicatricial  contraction.  Perichondritis 
of  the  laryngeal  or  tracheal  cartilages  may  follow,  and  result  in 
laryngeal  stenosis  requiring  tracheotomy.  The  damage  produced 
by  the  foreign  body  is  often  much  less  than  that  caused  by  blind 
and  ill-advised  attempts  at  removal.  If  the  foreign  body  becomes 
dislodged  and  moves  downward,  the  danger  of  intestinal  perfora- 


FOREIGN   BODIES    IN    THE    ESOPHAGUS  155 

tion  is  encountered.     The  prognosis,  therefore,  must  be  guarded 
so  long  as  the  intruder  remains  in  the  body. 

Treatment.- — It  is  a  mistake  to  try  to  force  a  foreign  body 
into  the  stomach  with  the  stomach  tube  or  bougie.  Sounding 
the  esophagus  with  bougies  to  determine  the  level  of  the  obstruc- 
tion, or  to  palpate  the  nature  of  the  foreign  body,  is  unnecessary 
and  dangerous.  Esophagoscopy  should  not  be  done  without  a 
previous  roentgenographic  and  fluoroscopic  examination  of  the 
chest  and  esophagus,  except  for  urgent  reasons.  The  level  of  the 
stenosis,  and  usually  the  nature  of  the  foreign  body,  can  thus  be 
decided.  Blind  instrumentation  is  dangerous,  and  in  view  of  the 
safety  and  success  of  esophagoscopy,  reprehensible. 

If  for  any  reason  removal  should  be  delayed,  bismuth  sub- 
nitrate,  gramme  0.6,  should  be  given  dry  on  the  tongue  every 
four  hours.  It  will  adhere  to  the  denuded  surfaces.  The  addition 
of  calomel,  gramme  0.003,  ^or  a  few  doses  will  increase  the  anti- 
septic action.  Should  swallowing  be  painful,  gramme  0.2  of 
orthoform  or  anesthesin  will  be  helpful.  Emetics  are  inefficient 
and  dangerous.  Holding  the  patient  up  by  the  heels  is  rarely, 
if  ever,  successful  if  the  foreign  body  is  in  the  esophagus.  In 
the  reported  cases   the  intruder  was  probably  in  the  pharynx. 

External  esophagotomy  for  the  removal  of  foreign  bodies  is 
unjustifiable  until  esophagoscopy  has  failed  in  the  hands  of  at 
least  two  skillful  esophagoscopists.  It  has  been  the  observation 
in  the  Bronchoscopic  Clinic  that  every  foreign  body  that  has  gone 
down  through  the  mouth  into  the  esophagus  can  be  brought 
back  the  same  way,  unless  it  has  already  perforated  the  esophageal 
wall,  in  which  event  it  is  no  longer  a  case  of  foreign  body  in  the  esoph- 
agus. The  mortality  of  external  esophagotomy  for  foreign  bodies 
is  from  twenty  to  forty- two  per  cent,  while  that  of  esophagos- 
copy is  less  than  two  per  cent,  if  the  foreign  body  has  not  already 
set  up  a  serious  complication  before  the  esophagoscopy.     Further- 


1 86  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

more,  external  esophagotomy  can  be  successful  only  with  objects 
lodged  in  the  cervical  esophagus  and,  moreover,  it  has  happened 
that  after  the  esophagus  has  been  opened,  the  foreign  body  could 
not  be  found  because  of  dislodgement  and  passage  downward 
during  the  relaxation  of  the  general  anesthesia.  Should  this  occur 
during  esophagoscopy,  the  foreign  body  can  be  followed  with  the 
esophagoscope,  and  even  if  it  is  not  overtaken  and  removed,  no 
risk  has  been  incurred. 

Esophagoscopy  is  the  one  method  of  removal  worthy  of  serious 
consideration.  Should  it  repeatedly  fail  in  the  hands  of  two 
skillful  endoscopists,  which  will  be  very  rarely,  if  ever,  then  exter- 
nal operation  is  to  be  considered  in  cervically  lodged  foreign  bodies. 


CHAPTER  XIX 
ESOPHAGOSCOPY  FOR  FOREIGN  BODY 

Indications. — Esophagoscopy  is  demanded  in  every  case  in 
which  a  foreign  body  is  known  to  be,  or  suspected  of  being,  in  the 
esophagus. 

Contraindications. — -There  is  no  absolute  contraindication 
to  careful  esophagoscopy  for  the  removal  of  foreign  bodies,  even 
in  the  presence  of  aneurism,  serious  cardiovascular  disease,  hyper- 
tension or  the  like,  although  these  conditions  would  render  the 
procedure  inadvisable.  Should  the  patient  be  in  bad  condition 
from  previous  ill-advised  or  blind  attempts  at  extraction,  endos- 
copy should  be  delayed  until  the  traumatic  esophagitis  has  sub- 
sided and  the  general  state  improved.  It  is  rarely  the  foreign 
body  itself  which  is  producing  these  symptoms,  and  the  removal 
of  the  object  will  not  cause  their  immediate  subsidence;  while  the 
passage  of  the  tube  through  the  lacerated,  infected,  and  inflamed 
esophagus  might  further  harm  the  patient.  Moreover,  the 
foreign  body  will  be  difficult  to  find  and  to  remove  from  the  edema- 
tous and  bleeding  folds,  and  the  risk  of  following  a  false  passage 
into  the  mediastinum  or  overriding  the  foreign  body  is  great. 
Water  starvation  should  be  relieved  by  means  of  proctoclysis 
and  hypodermoclysis  before  endoscopy  is  done.  The  esophagitis 
is  best  treated  by  placing  dry  on  the  tongue  at  four-hour  intervals 
the  following  powder : 

I^.     Anesthesin gramme  o.  1 2 

Bismuth  subnitrate gramme  0.6 

Calomel,  gramme  0.006  to  0.003  may  be  added  to  each  powder 

for  a  few  doses  to  increase  the  antiseptic  effect.     If  the  patient 

187 


155  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

can  swallow  liquids  it  is  best  to  wait  one  week  from  the  time  of  the 
last  attempt  at  removal  before  any  endoscopy  for  extraction  be 
done.  This  will  give  time  for  nature  to  repair  the  damage  and 
render  the  removal  of  the  object  more  certain  and  less  hazardous. 
Perforation  of  the  esophagus  by  the  foreign  body,  or  by  blind 
instrumentation,  is  a  contraindication  to  esophagoscopy.  It  is 
manifested  by  such  signs  as  subcutaneous  emphysema,  swelling  of 
the  neck,  fever,  irritability,  increase  in  pulsatory  and  respiratory 
rates,  and  pain  in  the  neck  or  chest.  Gaseous  emphysema  is 
present  in  some  cases,  and  denotes  a  dangerous  infection.  Eso- 
phagoscopy should  be  postponed  and  the  treatment  mentioned 
at  the  end  of  this  chapter  instituted.  After  the  subsidence  of  all 
symptoms  other  than  esophageal,  esophagoscopy  may  be  done 
safely.  Pleural  perforation  is  manifested  by  the  usual  signs  of 
pneumothorax,  and  will  be  demonstrated  in  the  roentgenogram. 

ESOPHAGOSCOPIC  EXTRACTION  OF  FOREIGN  BODIES 

It  is  unwise  to  do  an  endoscopy  in  a  foreign-body  case  for  the 
sole  purpose  of  taking  a  preliminary  look.  Everything  likely  to 
be  needed  for  extraction  of  the  intruder  should  be  sterile  and 
ready  at  hand.  Furthermore,  all  required  instruments  for  laryn- 
goscopy, bronchoscopy  or  tracheotomy  should  be  prepared  as  a 
matter  of  routine,  however  rarely  they  may  be  needed. 

Sponging  should  be  done  cautiously  lest  the  foreign  body  be 
hidden  in  secretions  or  food  accumulation,  and  dislodged.  Small 
food  masses  often  lodge  above  the  foreign  body  and  are  best 
removed  with  forceps.  The  folds  of  the  esophagus  are  to  be 
carefully  searched  with  the  aid  of  the  lip  of  the  esophagoscope. 
If  the  mucosa  of  the  esophagus  is  lacerated  with  the  forceps  all 
further  work  is  greatly  hampered  by  the  oozing;  if  the  laceration 
involve  the  esophageal  wall  the  accident  may  be  fatal:  and  at 


ESOPHAGOSCOPY    FOR    FOREIGN   BODY 


189 


best  the  tendency  of  the  tube-mouth  to  enter  the  laceration  and 
create  a  false  passage  is  very  great. 

"Overriding"'  or  failure  to  find  a  foreign  body  known  to  be 
present  is  explained  by  the  collapsed  walls  and  folds  covering  the 
object,  since  the  esophagoscope  cannot  be  of  sufificient  size  to 
smooth  out  these  folds,  and  still  be  of  small  enough  diameter  to 


E6of)ha^o- 

6C0JDe- 


FiG.  gi. — llluslrating  the  hiding  of  a  coin  by  the  folding  downward  of  the  pHca 
cricopharyngeus.  The  muscular  contraction  throws  the  beak  of  the  esophagoscope 
upward  while  the  interposed  tissue  prevents  the  tactile  appreciation  of  contact  of  the 
foreign  body  with  the  side  of  the  tube  after  the  tip  has  passed  over  the  foreign  body. 
Other  folds  may  in  rare  instances  act  similarly  in  hiding  a  foreign  body  from  view. 
This  overriding  of  a  foreign  body  is  apt  to  cause  dangerous  dyspnea  by  compression 
of  the  party  wall. 

pass  the  constricted  points  of  the  esophagus  noted  in  the  chapter 
on  anatomy.  Objects  are  often  hidden  just  distal  to  the  crico- 
pharyngeal  fold,  which  furthermore  makes  a  veritable  chute  in 
throwing  the  end  of  the  tube  forward  to  override  the  foreign  body 
and  to  interpose  a  layer  of  tissue  between  the  tube  and  the  object, 
so  that  the  contact  at  the  side  of  the  tube  is  not  felt  as  the  tube 
passes  over  the  foreign  body  (Fig.  91).  The  chief  factors  in 
overriding  an  esophageal  foreign  body  are: 

I.  The  chute-like  effect  of  the  plica  cricopharyngeus. 


I  go  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

2.  The  chute-like  effect  of  other  folds. 

3.  The  lurking  of  the  foreign  body  in  the  unexplored  pyriform 
sinus. 

4.  The  use  of  an  esophagoscope  of  small  diameter. 

5.  The  obscuration  of  the  intruder  by  secretion  or  food  debris. 

6.  The  obscuration  of  the  intruder  by  its  penetration  of  the 
esophageal  wall. 

7.  The  obscuration  of  the  intruder  by  inflammatory  sequelae. 
The  esophageal  speculum  for  the  removal  of  foreign  bodies  is 

useful  when  the  object  is  not  more  than  2  cm.  below  the  cricoid 
in  a  child,  and  3  cm.  in  the  adult.  The  fold  of  the  cricopharyneus 
can  be  repressed  posteriorward  by  the  forceps  which  are  then  in 
position  to  grasp  the  object  when  it  is  found.  The  author's 
down-jaw  forceps  (Fig.  22)  are  very  useful  to  reach  down  back  of 
the  cricopharyngeal  fold,  because  of  the  often  small  posterior 
forceps  space.  The  speculum  has  the  disadvantage  of  not 
allowing  deeper  search  should  the  foreign  body  move  downward- 
In  infants,  the  child's  size  laryngoscope  may  be  used  as  an  eso- 
phageal speculum.  General  anesthesia  is  not  only  unnecessary 
but  dangerous,  because  of  the  dyspnea  created  by  the  endoscopic 
tube.  Local  anesthesia  is  unnecessary  as  well  as  dangerous  in 
children;  and  its  application  is  likely  to  dislodge  the  foreign  body 
unless  used  as  a  troche.     Forbes  esophageal  speculum  is  excellent. 

MECHANICAL  PROBLEMS  OF  ESOPHAGOSCOPIC  REMOVAL  OF  FOREIGN 

BODIES 

The  bronchoscopic  problems  considered  in  the  previous 
chapter  should  be  studied. 

The  extraction  of  transfixed  foreign  bodies  presents  much  the 
same  problem  as  those  in  the  bronchi,  though  there  is  no  limit  here 
to  the  distance  an  object  may  be  pushed  down  to  free  the  point. 
Thin,  sharp  foreign  bodies  such  as  bones,  dentures,  pins,  safety- 
pins,  etcetera,  are  often  found  to  lie  crosswise  in  the  esophagus, 
and  it  is  imperative  that  one  end  be  disengaged  and  the  long  axis 


ESOPHAGOSCOPY    FOR   POREIGX  BODY 


191 


Fig.  92. — The  problem  of  the  horizontally  transfixed  foreign  body  in  the  esoph- 
agus. The  point,  D,  had  caught  as  the  bone,  A,  was  being  swallowed.  The 
end,  E,  was  forced  down  to  C,  by  food  or  by  blind  attempts  at  pushing  the  bone 
downward.  The  wall,  F,  should  be  laterally  displaced  to  J,  with  the  esophagoscope, 
permitting  the  forceps  to  grasp  the  end,  M,  of  the  bone.  Traction  in  the  direction 
of  the  dart  will  disimpact  the  bone  and  permit  it  to  rotate.  The  rotation  forceps  are 
used  as  at  K. 


Fig.  93. — Solution  of  the  mechanical  problem  of  the  broad  foreign  body  having  a 
sharp  point  by  version.  If  withdrawn  with  plain  forceps  as  applied  at  A,  the 
point  B,  will  rip  open  the  esophageal  wall.  If  grasped  at  C,  the  point,  D,  will 
rotate  in  the  direction  of  F  and  will  trail  harmlessly.  To  permit  this  version  the 
rotation  forceps  are  used  as  at  H.  On  this  principle  flat  foreign  bodies  with  jagged 
or  rough  parts  are  so  turned  that  the  potentially  traumatizing  parts  trail  during 
withdrawal. 


192  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

of  the  object  be  made  to  correspond  to  that  of  the  esophagus 
before  traction  for  removal  is  made  (Fig.  92) .  Should  the  intruder 
be  grasped  in  the  center  and  traction  exerted,  serious  and  perhaps 
fatal  trauma  might  ensue. 

The  extraction  of  broad,  flat  foreign  bodies  having  a  sharp 
point  or  a  rough  place  on  part  of  their  periphery  is  best  accom- 
plished by  the  method  of  rotation  as  shown  in  Fig.  93. 

Extraction  of  Open  Safety-pins  from  the  Esophagus. — An  open 
safety  pin  with  the  point  down  offers  no  particular  mechanical 
difficulty  in  removal.  Great  care  must  be  exercised,  however, 
that  it  be  not  overridden  or  pushed  upon,  as  either  accident  might 
result  in  perforation  of  the  esophagus  by  the  pin  point.  The 
coiled  spring  is  to  be  sought,  and  when  found,  seized  with  the 
rotation  forceps  and  the  pin  thus  drawn  into  the  esophago scope 
to  effect  closure.  An  open  safety-pin  lodged  point  upward  in  the 
esophagus  is  one  of  the  most  difficult  and  dangerous  problems. 
A  roentgenogram  should  always  be  made  in  the  plane  showing 
the  widest  spread  of  the  pin.  It  is  to  be  remembered  that  the 
endoscopist  can  see  but  one  portion  of  the  pin  at  a  time  (except  in 
cases  of  very  small  safety-pins)  and  that  if  he  grasps  the  part 
first  showing,  which  is  almost  invariably  the  keeper,  fatal  trauma 
will  surely  be  inflicted  when  traction  is  made.  It  may  be  best  to 
close  the  safety  pin  with  the  safety-pin  closer,  as  illustrated  in 
Fig.  37.  For  this  purpose  Arrowsmith's  closer  is  excellent.  In 
other  cases  it  may  prove  best  to  disengage  the  point  of  the  pin 
and  to  bring  the  pointed  shaft  into  the  esophagoscope  with  the 
Tucker  forceps  and  withdraw  the  pin,  forceps,  and  esophagoscope, 
with  the  keeper  and  its  shaft  sliding  alongside  the  tube.  The 
rounded  end  of  the  keeper  lying  outside  the  tube  allows  it  to  slip 
along  the  esophageal  walls  during  withdrawal  without  inflicting 
trauma;  however,  should  resistance  be  felt,  withdrawal  must 
immediately  cease  and  the  pin  must  be  rotated  into  a  different 


ESOPHAGOSCOPY   FOR   FOREIGN  BODY  IqS 

plane  to  release  the  keeper  from  the  fold  in  which  it  has  probably 
caught.  The  sense  of  touch  will  aid  the  sense  of  sight  in  the 
execution  of  this  maneuver  (Fig.  87).  When  the  pin  reaches  the 
cricopharyngeal  level  the  esophagoscope,  forceps,  and  pin  should 
be  turned  so  that  the  keeper  will  be  to  the  right,  not  so  much 
because  of  the  cricopharyngeal  muscle  as  to  escape  the  posteriorly 
protuberant  cricoid  cartilage.  In  certain  cases  in  which  it  is  found 
that  the  pointed  shaft  of  a  small  safety  pin  has  penetrated  the 
esophageal  wall,  the  pin  has  been  successfully  removed  by  working 
the  keeper  into  the  tube  mouth,  grasping  the  keeper  with  the 
rotation  forceps  or  side-curved  forceps,  and  pulling  the  whole  pin 
into  the  tube  by  straightening  it.  This,  however,  is  a  dangerous 
method  and  applicable  in  but  few  cases.  It  is  better  to  disengage 
the  point  by  downward  and  inward  rotation  with  the  Tucker 
forceps. 

Version  of  a  Safety  Pin. — A  safety  pin  of  very  small  size  may 
be  turned  over  in  a  direction  that  will  cause  the  point  to  trail. 
An  advancing  point  will  puncture.  This  is  a  dangerous  procedure 
with  a  large  safety  pin. 

Endogastric  Version.- — A  very  useful  and  comparatively  safe 
method  is  illustrated  in  Figs.  94  and  95.  In  the  execution  of 
this  maneuver  the  pin  is  seized  by  the  spring  with  a  rotation 
forceps,  and  thus  passed  along  with  the  esophagoscope  into  the 
stomach  where  it  is  rotated  so  that  the  spring  is  uppermost.  It 
can  then  be  drawn  into  the  tube  mouth  so  as  to  protect  the  tissues 
during  withdrawal  of  the  pin,  forceps,  and  esophagoscope  as  one 
piece.  Only  very  small  safety-pins  can  be  withdrawn  through 
the  esophagoscope. 

Spatula-protected  Method. — Safety-pins  in  children,  point 
upward,  when  lodged  high  in  the  cervical  esophagus  may  be 
readily  removed  with  the  aid  of  the  laryngoscope,  or  esophageal 
speculum.     The  keeper  end  is  grasped  with  the  alligator  forceps, 

13 


194 


BRONCHOSCOPY  AND  ESOPHAGOSCOPY 


while  the  spatular  tip  of  the  laryngoscope  is  worked  under  the 
point.  Instruments  and  foreign  body  are  then  removed  together. 
Often  the  pin  point  will  catch  in  the  light-chamber  where  it 
is  very  safely  lodged.  If  the  pin  be  then  pulled  upon  it  will 
straighten  out  and  may  be  withdrawn  through  the  tube. 


Fig.  94. — Endogastric  version.  One  of  the  author's  methods  of  removal  of 
upward  pointed  esophageally  lodged  open  safety-pins  by  passing  them  into  stomach, 
where  they  are  turned  and  removed.  The  first  illustration  (A)  shows  the  rotation 
forceps  before  seizing  pin  by  the  ring  of  the  spring  end.  (Forceps  jaws  are  shown 
opening  in  the  wrong  diameter.)  At  B  is  shown  the  pin  seized  in  the  ring  by  the 
points  of  the  forceps.  At  C  is  shown  the  pin  carried  into  the  stomach  and  about  to 
be  rotated  by  withdrawal.  D,  the  withdrawal  of  the  pin  into  the  esophagoscope 
which  will  thereby  close  it.  If  withdrawn  by  flat-jawed  forceps  as  at  F,  the  eso- 
phageal wall  would  be  fatally  lacerated. 


Double  pointed  tacks  and  staples,  when  lodged  point  upward, 
must  be  turned  so  that  the  points  trail  on  removal.  This  may  be 
done  by  carrying  them  into  the  stomach  and  turning  them,  as 
described  under  safety-pins. 

The  extraction  of  foreign  bodies  of  very  large  size  from  the  esoph- 
agus is  greatly  facilitated  by  the  use  of  general  anesthesia,  which 


ESOPHAGOSCOPY    FOR    FOREIGN   BODY  1 95 

relaxes  the  spasmodic  contractions  of  the  esophagus  often  occur- 
ring when  attempt  is  made  to  withdraw  the  foreign  body.  General 
anesthesia,  though  entirely  unnecessary  for  introduction  of  the 


Fig.  95. — Lateral  roentgenogram  of  a  safety-pin  in  a  child  aged  11  months, 
demonstrating  the  esophageal  location  of  the  pin  in  this  case  and  the  great  value  of 
the  lateral  roentgenogram  in  the  localization  of  foreign  bodies.  The  pin  was 
removed  by  the  author's  method  of  endogastric  version.  (Plate  made  by  George 
C.  Johnston  ) 

esophagoscope,  in  any  case  may  be  used  if  the  body  is  large,  sharp, 
and  rough,  in  order  to  prevent  laceration  through  the  muscular 
contractions  otherwise  incident  to  withdrawal.*  In  exceptional 
cases  it  may  be  necessary  to  comminute  a  large  foreign  body  such 

*  It  must  always  be  remembered  that  large  foreign  bodies  are  very  prone  to  cause 
dyspnea  that  renders  general  anesthesia  e.xceedingly  dangerous  especially  in  children. 


196  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

as  a  tooth  plate.  A  large  smooth  foreign  body  may  be  difficult 
to  seize  with  forceps.  In  this  case  the  mechanical  spoon  or  the 
author's  safety-pin  closer  may  be  used. 

The  extraction  of  meat  and  other  foods  from  the  esophagus  at  the 
level  of  the  upper  thoracic  aperture  is  usually  readily  accomplished 
with  the  esophageal  speculum  and  forceps.  In  certain  cases 
the  mechanical  spoon  will  be  found  useful.  Should  the  bolus 
of  food  be  lodged  at  the  lower  level  the  esophagoscope  will  be 
required. 

Extraction  of  Foreign  Bodies  from  the  Strictured  Esophagus.- — 
Foreign  bodies  of  relatively  small  size  will  lodge  in  a  strictured 
esophagus.  Removal  may  be  rendered  difficult  when  the  patient 
has  an  upper  stricture  relatively  larger  than  the  lower  one,  and  the 
foreign  body  passing  the  first  one  lodges  at  the  second.  Still 
more  difficult  is  the  case  when  the  second  stricture  is  considerably 
below  the  first,  and  not  concentric.  Under  these  circumstances 
it  is  best  to  divulse  the  upper  stricture  mechanically,  when  a  small 
tube  can  be  inserted  past  the  first  stricture  to  the  site  of  lodgement 
of  the  foreign  body . 

Prolonged  sojourn  of  foreign  bodies  in  the  esophagus,  while 
not  so  common  as  in  the  bronchi  is  by  no  means  of  rare  occurrence. 
Following  their  removal,  stricture  of  greater  or  less  extent  is 
almost  certain  to  follow  from  contraction  of  the  fibrous-tissue 
produced  by  the  foreign  body. 

Fluoroscopic  esophagoscopy  is  a  questionable  procedure,  for 
the  esophagus  can  be  explored  throughout  by  sight.  In  cases  in 
which  it  is  suspected  that  a  foreign  body,  such  as  pin,  has  partially 
escaped  from  the  esophagus,  the  fluoroscope  may  aid  in  a  detailed 
search  to  determine  its  location,  but  under  no  circumstances  should 
it  be  the  guide  for  the  application  of  forceps,  because  the  trans- 
parent but  vital  tissues  are  almost  certain  to  be  included  in  the 
grasp. 


ESOPHAGOSCOPY  FOR  FOREIGN  BODY  1 97 

Complications  and  Dangers  of  Esophagoscopy  for  Foreign  Bodies. 
Asphyxia  from  the  pressure  of  the  foreign  body,  or  the  foreign 
body  plus  the  esophagoscope,  is  a  possibility  (Fig.  91).  Faulty 
position  of  the  patient,  especially  a  low  position  of  the  head,  with 
faulty  direction  of  the  esophagoscope  may  cause  the  tube  mouth  to 
press  the  membranous  tracheo-esophageal  wall  into  the  trachea,  so 
as  temporarily  to  occlude  the  tracheal  lumen,  creating  a  very 
dangerous  situation  in  a  patient  under  general  anesthesia.  Prompt 
introduction  of  a  bronchoscope,  with  oxygen  and  amyl  nitrite 
insufflation  and  artificial  respiration,  may  be  necessary  to  save 
life.  The  danger  is  greater,  of  course,  with  chloroform  than  with 
ether  anesthesia.  Cocain  poisoning  may  occur  in  those  having 
an  idiosyncrasy  to  the  drug.  Cocain  should  never  be  used  with 
children,  and  is  of  little  use  in  esophagoscopy  in  adults.  Its 
application  is  more  annoying  and  requires  more  time  than  the 
esophagoscopic  removal  of  the  foreign  bodies  without  local 
anesthesia.  Traumatic  esophagitis,  septic  mediastinitis,  cervical 
cellulitis,  and,  most  dangerous,  gangrenous  esophagitis  may  be 
present,  caused  by  the  foreign  body  itself  or  ill-advised  efforts  at 
removal.  Perforation  of  the  esophagus  with  the  esophagoscope 
is  rare,  in  skillful  hands,  if  the  esophageal  wall  is  sound.  The 
esophageal  wall,  however,  may  be  weakened  by  ulceration,  malig- 
nant disease,  or  trauma,  so  that  the  possibility  of  making  a  false 
passage  should  always  deter  the  endoscopist  from  advancing  the 
tube  beyond  a  visible  point  of  weakening.  To  avoid  entering  a 
false  passage  previously  created,  is  often  exceedingly  difficult,  and 
usually  it  is  better  to  wait  for  obliterative  adhesive  inflammation 
to  seal  the  tissue  layers  together. 

Treatment. — Acute  esophagitis  calls  for  rest  in  bed,  sterile 
liquid  food,  and  the  administration  of  bismuth  powder  mentioned 
in  the  paragraph  on  contraindications.     An  ice  bag  applied  to  the 


198  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

neck  may  afford  some  relief.  The  mouth  should  be  hourly  cleansed 
with  the  following  solution: 

Dakin's  solution     i  part 
Cinnamon  water    5  parts. 

Emphysema  unaccompanied  by  pyogenic  processes  usually 
requires  no  treatment,  though  an  occasional  case  may  require 
punctures  of  the  skin  to  liberate  the  air.  Gaseous  emphysema 
and  pus  formation  urgently  demand  early  external  drainage, 
preferably  behind  the  sternomastoid.  Should  the  pleura  be 
perforated  by  sudden  puncture  pyo-pneumo thorax  is  inevitable. 
Prompt  thoracotomy  for  drainage  may  save  the  patient's  life 
if  the  mediastinum  has  not  also  been  infected.  Foreign  bodies 
ulcerating  through  may  reach  the  lung  without  pleural  leakage 
because  of  the  sealing  together  of  the  visceral  and  parietal  pleurae. 
In  the  serious  degrees  of  esophageal  trauma,  particularly  if  the 
pleura  be  perforated,  gastrostomy  is  indicated  to  afford  rest  of 
the  esophagus,  and  for  alimentation.  A  duodenal  feeding  tube 
may  be  placed  through  an  esophagoscope  passed  into  the  stomach 
in  the  usual  way  through  the  mouth,  avoiding  by  ocular  guidance 
the  perforation  into  which  a  blindly  passed  stomach  tube  would  be 
very  likely  to  enter,  with  probably  dangerous  results. 


CHAPTER  XX 
PLEUROSCOPY 

Foreign  bodies  in  the  pleural  cavity  should  be  immediately 
removed.  The  esophageal  speculum  inserted  through  a  small 
intercostal  incision  makes  an  excellent  pleuroscope,  its  spatular 
tip  being  of  particular  value  in  moving  the  lung  out  of  the  way. 
This  otherwise  dark  cavity  is  thus  brilliantly  illuminated  without 
the  necessity  of  making  a  large  flap  resection,  an  important 
factor  in  those  cases  in  which  there  is  no  infection  present.  The 
pleura  and  wound  may  be  immediately  closed  without  drainage, 
if  the  pleura  is  not  infected.  Excessive  plus  pressure  or  pus  may 
require  reopening.  In  one  case  in  which  the  author  removed  a 
foreign  body  by  pleuroscopy,  healing  was  by  first  intention  and 
the  lung  filled  in  a  few  days.  Drainage  tubes  that  have  slipped 
up  into  the  empyemic  cavity  are  foreign  bodies.  They  are 
readily  removed  with  the  retrograde  esophagoscope  even  through 
the  smallest  fistula.  The  aspirating  canal  keeps  a  clear  field  while 
searching  for  the  drain. 

Pleuroscopy  for  Disease. — Most  pleural  diseases  require  a  large 
external  opening  for  drainage,  and  even  here  the  pleuroscope  may 
be  of  some  use  in  exploring  the  cavities.  Usually  there  are  many 
adhesions  and  careful  ray  study  may  reveal  one  or  more  the 
breaking  up  of  which  will  improve  drainage  to  such  an  extent  as 
to  cure  an  empyema  of  long  standing.  Repeated  severing  of 
adhesions,  aspiration  and  sometimes  incision  of  the  thickened 
visceral  pleura  may  be  necessary.     The  author  is  so  strongly 

imbued  with  the  idea  that  local  examination  under  full  illumina- 

199 


200  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

tion  has  so  revolutionized  the  surgery  of  every  region  of  the  body 
to  which  it  has  been  applied,  that  every  accessible  region  should  be 
thus  studied.  The  pleural  cavity  is  quite  accessible  with  or 
without  rib-resection,  and  there  is  practically  no  risk  in  careful 
pleuroscopy. 


CHAPTER  XXI 
BENIGN  GROWTHS  IN  THE  LARYNX 

Benign  growths  in  the  larynx  are  easily  and  accurately  remov- 
able by  direct  laryngoscopy;  but  perhaps  no  method  has  been  more 
often  misused  and  followed  by  most  unfortunate  results.  It 
should  always  be  remembered  that  benign  growths  are  benign, 
and  that  hence  they  do  not  justify  the  radical  work  demanded 
in  dealing  with  malignancy.  The  larynx  should  be  worked  upon 
with  the  same  delicacy  and  respect  for  the  normal  tissues  that  are 
customary  in  dealing  with  the  eye. 

Granulomata  in  the  larynx,  while  not  true  neoplasms,  require 
extirpation  in  some  instances. 

Vocal  nodules,  when  other  methods  of  cure  such  as  vocal  rest, 
various  vocal  exercises,  etcetera  have  failed  may  require  surgical 
excision.  This  may  be  done  with  the  laryngeal  tissue  forceps  or 
with  the  author's  vocal  nodule  forceps.  Sessile  vocal  nodules 
may  be  cured  by  touching  them  with  a  fine  galvanocautery  point, 
but  all  work  on  the  vocal  cords  must  be  done  with  extreme  caution 
and  nicety.     It  is  exceedingly  easy  to  ruin  a  fine  voice. 

Fibromata,  often  of  inflammatory  genesis,  are  best  removed 
with  the  laryngeal  grasping  forceps,  though  the  small  laryngeal 
punch  or  tissue  forceps  may  be  used.  If  very  large,  they  may  be 
amputated  with  the  snare,  the  base  being  treated  with  galvano- 
cautery though  this  is  seldom  advisable.  Strong  traction  should 
be  avoided  as  likely  to  do  irreparable  injury  to  the  laryngeal 
motility. 

Cystomata  may  get  well  after  simple  excision  or  galvanopunc- 
ture  of  a  part  of  the  wall  of  the  sac,  but  complete  extirpation  of 
the  sac  is  often  required  for  cure.     The  same  is  true  of  adenomata. 


202  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

Angiomata,  if  extensive  and  deeply  seated,  may  require  deep 
excision,  but  usually  cure  results  from  superficial  removal. 
Usually  no  cauterization  of  the  vessels  at  the  base  is  necessary, 
either  to  arrest  hemorrhage  or  to  lessen  the  tendency  to  recurrence. 
A  diffuse  telangiectasis,  should  it  require  treatment,  may  be 
gently  touched  with  a  needle-pointed  galvanocaustic  electrode 
at  a  number  of  sittings.  The  galvanonocautery  is  a  dangerous 
method  to  use  in  the  larynx.  Radium  offers  the  best  results  in 
this  latter  form  of  angioma,  applied  either  internally  or  to  the  neck. 

Lymphoma,  enchondroma  and  osteoma,  if  not  too  extensively 
involving  the  laryngeal  walls,  may  be  excised  with  basket  punch 
forceps,  but  lymphoma  is  probably  better  treated  by  radium.* 
True  myxomata  and  lipomata  are  very  rare.  Amyloid  tumors  are 
occasionally  met  with,  and  are  very  resistant  to  treatment. 
Aberrant  thyroid  tumors  do  not  require  very  radical  excision  of 
normal  base,  but  should  be  removed  as  completely  as  possible. 

In  a  general  way,  it  may  be  stated  that  with  benign  growths 
in  the  larynx  the  best  functional  results  are  obtained  by  superficial 
rather  than  radical,  deep  extirpation,  remembering  that  it  is  easier 
to  remove  tissue  than  to  replace  it,  and  that  cicatrices  impair  or 
ruin  the  voice  and  may  cause  stenosis. 

*  In  a  case  reported  by  Delavan  a  complete  cure  with  perfect  restoration  of 
voice  resulted  from  radium  after  I  had  failed  to  cure  by  operative  methods.  (Pro- 
ceedings American  Laryngolo^cal  Association,  192 1.) 


5rJ5JJ0 


CHAPTER  XXII 

BENIGN  GROWTHS  IN  THE  LARYNX  {Continued) 

PAPILLOMATA  OF  THE  LARYNX  m  CHILDREN 

Of  all  benign  growths  in  the  larynx  papilloma  is  the  most 
frequent.  It  may  occur  at  any  age  of  childhood  and  may  even 
be  congenital.  The  outstanding  fact  which  necessarily  influences 
our  treatment  is  the  tendency  to  recurrences,  followed  eventually 
in  practically  all  cases  by  a  tendency  to  disappearance.  In  the 
author's  opinion  multiple  papillomata  constitute  a  benign,  self- 
limited  disease.  There  are  two  classes  of  cases,  i.  Those  in 
which  the  growth  gets  well  spontaneously,  or  with  slight  treat- 
ment, surgically  or  otherwise;  and,  2,  those  not  readily  amenable 
to  any  form  of  treatment,  recurrences  appearing  persistently  at 
the  old  sites,  and  in  entirely  new  locations.  In  the  author's 
opinion  these  two  classes  of  case  represent  not  two  different  kinds 
of  growths,  but  stages  in  the  disease.  Those  that  get  well  after 
a  single  removal  are  near  the  end  of  the  disease.  Papillomata  are 
of  inflammatory  origin  and  are  not  true  neoplasms  in  the  strictest 
sense. 

Methods  of  Treatment. — Irritating  applications  probably  pro- 
voke recurrences,  because  the  growths  are  of  inflammatory  origin. 
Formerly  laryngostomy  was  recommended  as  a  last  resort  when 
all  other  means  had  failed.  The  excellent  results  from  the 
method  described  in  the  foregoing  paragraph  has  relegated  laryn- 
gostomy to  those  cases  that  come  in  with  a  severe  cicatricial 
stenosis  from  an  injudicious  laryngofissure;  and  even  in  these 
cases  cure  of  the  stenosis  as  well  as  the  papillomata  can  usually  be 

obtained  by  endoscopic  methods  alone,  using  superficial  scalping 

203 


204  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

off  of  the  papillomata  with  subsequent  laryngoscopic  bouginage 
for  the  stenosis.  Thyrotomy  for  papillomata  is  mentioned  only 
to  be  condemned.  Fulguration  has  been  satisfactory  in  the 
hands  of  some,  disappointing  to  others.  It  is  easily  and  accurately 
applied  through  the  direct  laryngoscope,  but  damage  to  normal 
tissues  must  be  avoided.  Radium,  mesothorium,  and  the 
roentgenray  are  reported  to  have  had  in  certain  isolated  cases  a 
seemingly  beneficial  action.  In  my  experience,  however,  I  have 
never  seen  a  cure  of  papillomata  which  could  be  attributed  to 
the  radiation.  I  have  seen  cases  in  which  no  effect  on  the 
growths  or  recurrence  was  apparent,  and  in  some  cases  the  growths 
seemed  to  have  been  stimulated  to  more  rapid  repullulations.  In 
other  most  unfortunate  cases  I  have  seen  perichondritis  of  the 
laryngeal  cartilages  with  subsequent  stenosis  occurring  after  the 
roentgenotherapy.  Possibly  the  disastrous  results  were  due  to 
overdosage;  but  I  feel  it  a  duty  to  state  the  unfavorable  experience, 
and  to  call  attention  to  the  difference  between  cancer  and  papillo- 
mata. Multiple  papillomata  involve  no  danger  to  life  other  than 
that  of  easily  obviated  asphyxia,  and  it  is  moreover  a  benign 
self-limited  disease  that  repullulates  on  the  surface.  In  cancer 
we  have  an  infiltrating  process  that  has  no  limits  short  of  life 
itself. 

Endolaryngeal  extirpation  of  papillomata  in  children  requires 
no  anesthetic,  general  or  local;  the  growths  are  devoid  of  sensibil- 
ity. If,  for  any  reason,  a  general  anesthetic  is  used  it  should  be 
only  in  tracheotomized  cases,  because  the  growths  obstruct  the 
airway.  Obstructed  respiration  introduces  into  general  anesthesia 
an  enormous  element  of  danger.  Concerning  the  treatment  of  mul- 
tiple papillomata  it  has  been  my  experience  in  hundreds  of  cases 
that  have  come  to  the  Bronchoscopic  Clinic,  that  repeated  super- 
ficial removals  with  blunt  non-cutting  forceps  (see  Chapter  I)  will 
so  modify  the  soil  as  to  make  it  unfavorable  for  repullulation.     The 


BENIGN    GROWTHS    IN    THE    LARYNX  205 

removals  are  superficial  and  do  not  include  the  subjacent  nor- 
mal tissue.  Radical  removal  of  a  papilloma  situated,  for  in- 
stance, on  the  left  ventricular  band  or  cord,  can  in  no  way  pre- 
vent the  subsequent  occurrence  of  a  similar  growth  at  a  different 
site,  as  upon  the  epiglottis,  or  even  in  the  fauces.  Furthermore, 
radical  removal  of  the  basal  tissues  is  certain  to  impair  the 
phonatory  function.  Excellent  results  as  to  voice  and  freedom 
from  recurrence  have  always  followed  repeated  superficial  removal. 
The  time  required  has  been  months  or  a  year  or  two.  Only 
rarely  has  a  cure  followed  a  single  extirpation. 

If  the  child  is  but  slightly  dyspneic,  the  obstructing  part  of  the 
growth  is  first  removed  without  anesthesia,  general  or  local;  the 
remaining  fungations  are  extirpated  subsequently  at  a  number  of 
brief  seances.  The  child  is  thus  not  terrified,  soon  loses  dread  of 
the  removals,  and  appreciates  the  relief.  Should  the  child  be  very 
dyspneic  when  first  seen,  a  low  tracheotomy  is  immediately  done, 
and  after  an  interim  of  ten  days,  laryngoscopic  removal  of  the 
growth  is  begun.  Tracheotomy  probably  has  a  beneficial  effect 
on  the  disease.  Tracheal  growths  require  the  insertion  of  the 
bronchoscope  for  their  removal. 

Papillomata  in  the  larynx  of  adults  are,  on  the  whole,  much 
more  amenable  to  treatment  than  similar  growths  in  children. 
Tracheotomy  is  very  rarely  required,  and  the  tendency  to  recur- 
rence is  less  marked.  Many  are  cured  by  a  single  extirpation. 
The  best  results  are  obtained  by  removal  of  the  growths  with  the 
laryngeal  grasping-forceps,  taking  the  utmost  care  to  avoid  includ- 
ing in  the  bite  of  the  forceps  any  of  the  subjacent  normal  tissue. 
Radical  resection  or  cauterization  of  the  base  is  unwise  because  of 
the  probable  impairment  of  the  voice,  or  cicatricial  stenosis,  with- 
out in  anyway  insuring  against  repullulation.  The  papillomata  are 
so  soft  that  they  give  no  sensation  of  traction  to  the  forceps.  They 
can  readily  be  "scalped"  off  without  any  impairment  of  the  sound 


2o6  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

tissues,  by  the  use  of  the  author's  papilloma  forceps  (Fig.  29). 
Cutting  forceps  of  all  kinds  are  objectionable  because  they  may 
wound  the  normal  tissues  before  the  sense  of  touch  can  give 
warning.  A  gentle  hand  might  be  trusted  with  the  cup  forceps 
(Fig.  32,  large  size.) 

Sir  Felix  Semon  proved  conclusively  by  his  collective  investi- 
gations that  cancer  cannot  be  caused  by  the  repeated  removals 
of  benign  growths.  Therefore,  no  fear  of  causing  cancer  need  give 
rise  to  hesitation  in  repeatedly  removing  the  repullulations  of 
papillomata  or  other  benign  growths.  Indeed  there  is  much  clin- 
ical evidence  elsewhere  in  the  body,  and  more  than  a  little  such 
evidence  as  to  the  larynx,  to  warrant  the  removal  of  benign 
growths,  repeated  if  necessary,  as  a  prophylactic  of  cancer  (Bib- 
liography, 19). 


CHAPTER  XXIII 

BENIGN    GROWTHS  PRIMARY   IN   THE   TRACHEOBRON- 
CHIAL TREE 

Extension  of  papillomata  from  the  larynx  into  the  cervical 
trachea,  especially  about  the  tracheotomy  wound,  is  of  relatively 
common  occurrence.  True  primary  growths  of  the  tracheo- 
bronchial tree,  though  not  frequent,  are  by  no  means  rare.  These 
primary  growths  include  primary  papillomata  and  fibromata  as 
the  most  frequent,  aberrant  thyroid,  lipomata,  adenomata, 
granulomata  and  amyloid  tumors.  Chondromata  and  osteochon- 
dromata  may  be  benign  but  are  prone  to  develop  malignancy, 
and  by  sarcomatous  or  other  changes,  even  metaplasia.  Edema- 
tous polypi  and  other  more  or  less  tumor-like  inflammatory 
sequelae  are  occasionally  encountered. 

Symptoms  of  Benign  Tumors  of  the  Tracheobronchial  Tree. — 
Cough,  wheezing  respiration,  and  dyspnea,  varying  in  degree  with 
the  size  of  the  tumor,  indicate  obstruction  of  the  air-way.  Asso- 
ciated with  defective  aeration  will  be  the  signs  of  deficient  drainage 
of  secretions.  Roentgenray  examination  may  show  the  shadow 
of  enchondromata  or  osteomata,  and  will  also  show  variations 
in  aeration  should  the  tumor  be  in  a  bronchus. 

Bronchoscopic  removal  of  benign  growths  is  readily  accomplished 
with  the  endoscopic  punch  forceps  shown  in  Figs.  28  and  33. 
Quick  action  may  be  necessary  should  a  large  tumor  producing 
great  dyspnea  be  encountered,  for  the  dyspnea  is  apt  to  be  in- 
creased by  the  congestion,  cough,  and  increased  respiration  and 

207 


2o8  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

spasm  incidental  to  the  presence  of  the  bronchoscope  in  the  trachea. 
General  anesthesia,  as  in  all  cases  showing  dyspnea,  is  contraindi- 
cated.  The  risks  of  hemorrhage  following  removal  are  very  slight, 
provided  fungations  on  an  aneurismal  erosion  be  not  mistaken  for 
a  tumor. 

Multiple  papillomata  when  very  numerous  are  best  removed 
by  the  author's  "coring"  method.  This  consists  in  the  insertion 
of  an  aspirating  bronchoscope  with  the  mechanical  aspirator 
working  at  full  negative  pressure.  The  papillomata  are  removed 
like  coring  an  apple;  though  the  rounded  edge  of  the  bronchoscope 
does  not  even  scratch  the  tracheal  mucosa.  Many  of  the  papil- 
lomata are  taken  off  by  the  holes  in  the  bronchoscope.  Aspiration 
of  the  detached  papillomata  into  the  lungs  is  prevented  by  the 
corking  of  the  tube-mouth  with  the  mass  of  papillomata  held  by 
the  negative  pressure  at  the  canal  inlet  orifice. 


CHAPTER  XXIV 
BENIGN  NEOPLASMS  OF  THE  ESOPHAGUS 

As  a  result  of  prolonged  inflammation  edematous  polypi  and 
granulomata  are  not  infrequently  seen,  but  true  benign  tumors 
of  the  esophagus  are  rare  affections.  Keloidal  changes  in  scar 
tissue  may  occur.  Cases  of  retention,  epithelial  and  dermoid 
cysts  have  been  observed;  and  there  are  isolated  reports  of  the 
finding  of  papillomata,  fibromata,  lipomata,  myomata  and  adeno- 
mata. The  removal  of  these  is  readily  accomplished  with  the 
tissue  forceps  (Fig.  28),  if  the  growths  are  small  and  projecting 
into  the  esophageal  lumen.  The  determination  of  the  advisability 
of  the  removal  of  keloidal  scars  would  require  careful  consideration 
of  the  particular  case,  and  the  same  may  be  said  of  very  large 
growths  of  any  kind.  The  extreme  thinness  of  the  esophageal 
walls  must  be  always  in  the  mind  of  the  esophagoscopist  if  he 
would  avoid  disaster. 


14  209 


CHAPTER  XXV 
ENDOSCOPY  IN   MALIGNANT  DISEASE  OF  THE  LARYNX 

The  general  surgical  rule  applying  to  individuals  past  middle 
life,  that  benign  growths  exposed  to  irritation  should  be  removed, 
probably  applies  to  the  larynx  as  well  as  to  any  other  epithelialized 
structure.  The  facility,  accuracy  and  thoroughness  afforded  by 
skilled,  direct,  laryngeal  operation  offers  a  means  of  lessening  the 
incidence  of  cancer.  To  a  much  greater  extent  the  facility, 
accuracy,  and  thoroughness  contribute  to  the  cure  of  cancer  by 
establishing  the  necessary  early  diagnosis.  Well-planned,  careful, 
external  operation  (laryngofissure)  followed  by  painstaking  after- 
care is  the  only  absolute  cure  so  far  known  for  malignant  neoplasms 
of  the  larynx;  and  it  is  a  cure  only  in  those  intrinsic  cases  in  which 
the  growth  is  small,  and  is  located  in  the  anterior  two-thirds  of  the 
intrinsic  area.  By  limiting  operations  strictly  to  this  class  of 
case,  eighty-five  per  cent  of  cures  may  be  obtained.*  In  determin- 
ing the  nature  of  the  growth  and  its  operability  the  limits  of  the 
usefulness  of  direct  endoscopy  are  reached.  It  is  very  unwise  to 
attempt  the  extirpation  of  intrinsic  laryngeal  malignancy  by  the 
endoscopic  method,  for  the  reason  that  the  full  extent  of  the 
growth  cannot  be  appreciated  when  viewed  only  from  above, 
and  the  necessary  radical  removal  cannot  be  accurately  or  com- 
pletely accomplished. 

Malignant  disease  of  the  epiglottis,  in  those  rare  cases  where 
the  lesion  is  strictly  limited  to  the  tip  is,  however,  an  exception. 

*  The  author's  results  in  laryngofissure  have  recently  fallen  to  79  per  cent  of 
relative  cures  by  thyrochondrotomy. 


ENDOSCOPY    IN    MALIGNANT    DISEASE    OF    THE    LARYNX        211 

If  amputation  of  the  epiglottis  will  give  a  sutBciently  wide  removal, 
this  may  be  done  en  masse  with  a  heavy  snare,  and  has  resulted 
in  complete  cure.  Very  small  growths  may  be  removed  suffi- 
ciently widely  with  the  punch  forceps  (Fig.  _^t,);  but  piece  meal 
removal  of  malignancy  is  to  be  avoided. 

Differential  Diagnosis  of  Laryngeal  Growths  in  the  Larynx  of 
Adults. — Determination  of  the  nature  of  the  lesion  in  these  cases 
usually  consists  in  the  diagnosis  by  exclusion  of  the  possibilities, 
namely, 

1.  Lues. 

2.  Tuberculosis,  including  lupus. 

3.  Scleroma. 

4.  Malignant  neoplasm. 

In  the  Bronchoscopic  Clinic  the  following  is  the  routine 
procedure: 

1 .  A  Wassermann  test  is  made.  If  negative,  and  there  remains 
a  suspicion  of  lues,  a  therapeutic  test  with  mercury  protoiodid  is 
carried  out  by  keeping  the  patient  just  under  the  salivation  point 
for  eight  weeks;  during  which  time  no  potassium  iodid  is  given, 
lest  its  reaction  upon  the  larynx  cause  an  edema  necessitating 
tracheotomy.  If  no  improvement  is  noticed  lues  is  excluded. 
If  the  Wassermann  is  positive,  malignancy  and  the  other  possibili- 
ties are  not  considered  as  excluded  until  the  patient  has  been 
completely  cured  by  mercury,  because,  for  instance,  a  leutic  or 
tuberculous  patient  may  have  cancer;  a  tuberculous  patient  may 
have  lues;  or  a  leutic  patient,  tuberculosis. 

2.  Pulmonary  tuberculosis  is  excluded  by  the  usual  means. 
If  present  the  laryngeal  lesion  may  or  may  not  be  tuberculous;  if 
the  laryngoscopic  appearances  are  doubtful  a  specimen  is  taken. 
Lupoid  laryngeal  tuberculosis  so  much  resembles  lues  that  both  the 
therapeutic  test  and  biopsy  may  be  required  for  certainty. 

3.  In  all  cases  in  which  the  diagnosis  is  not  clear  a  specimen 


212  BRO^XHOSCOPY   AND    ESOPHAGOSCOPY 

is  taken.  This  is  readily  accomplished  by  direct  laryngoscopy 
under  local  anesthesia,  using  the  regular  laryngoscope  or  the  ante- 
rior commissure  laryngoscope.  The  best  forceps  in  case  of  large 
growths  are  the  alligator  punch  forceps  (Fig.  33) .  Smaller  growths 
require  tissue  forceps  (Fig.  28).  In  case  of  small  growths,  it  is 
best  to  remove  the  entire  growth;  but  without  any  attempt  at 
radical  extirpation  of  the  base;  because,  if  the  growth  prove  benign 
it  is  unnecessary;  if  malignant,  it  is  insufficient. 

Inspection  of  the  Party  Wall  in  Cases  of  Suspected  Laryngeal 
Malignancy.- — When  taking  a  specimen  the  party  wall  should  be 
inspected  by  passing  a  laryngoscope  or,  if  necessary,  an  esophageal 
speculum  down  through  the  laryngopharynx  and  beyond  the 
cricopharyngeus.  If  this  region  shows  infiltration,  all  hope  of 
cure  by  operation,  however  radical,  should  be  abandoned. 

Radium  and  the  therapeutic  roentgenray  have  given  good 
results,  but  not  such  as  would  warrant  their  exclusive  use  in  any 
case  of  malignancy  in  the  larynx  operable  by  laryngofissure. 
With  inoperable  cases,  excellent  palliative  results  are  obtained. 
In  some  cases  an  almost  complete  disappearance  of  the  growth 
has  occurred,  but  ultimately  there  has  been  recurrence.  The 
method  of  application  of  the  radium,  dosage,  and  its  screening, 
are  best  determined  by  the  radiologist  in  consultation  with  the 
laryngologist.  Radium  may  be  applied  externally  to  the  neck, 
or  suspended  in  the  larynx;  radium-containing  needles  may  be 
buried  in  the  growth,  or  the  emanations,  imprisoned  in  glass 
pearls  or  capillary  tubes,  may  be  inserted  deeply  into  the  growth 
by  means  of  a  small  trocar  and  cannula.  For  all  of  these  proce- 
dures direct  laryngoscopy  affords  a  ready  means  of  accurate 
application.  Tracheotomy  is  necessary  however,  because  of  the 
reactionary  swelling,  which  may  be  so  great  as  to  close  completely 
the  narrowed  glottic  chink.  Where  this  is  the  case,  the  endolaryn- 
geal  application  of  the  radium  may  be  made  by  inserting,  the. 


ENDOSCOPY    IN   MALIGNANT    DISEASE    OF    THE    LARYNX        213 

container  through  the  tracheotomic  wound,  and  anchoring  it  to 
the  cannula. 

The  author  is  much  impressed  with  Freer's  method  of  radiation 
from  the  pyriform  sinus  in  such  cases  as  those  in  which  external 
radiation  alone  is  deemed  insufhcient. 

The  work  of  Drs.  D.  Bryson  Delavan  and  Douglass  M.  Quick 
forms  one  of  the  most  important  contributions  to  the  subject  of 
the  treatment  of  radium  by  cancer.  (See  Proceedings  of  the 
American  Laryngological  Association,  1922;  also  Proceedings  of 
the  Tenth  International  Otological  Congress,  Paris,  1922.) 


CHAPTER  XXVI 

BRONCHOSCOPY  IN  MALIGNANT  GROWTHS  OF  THE 

TRACHEA 

The  trachea  is  often  secondarily  invaded  by  malignancy  of 
the  esophagus,  thyroid  gland,  peritracheal  or  peribronchial 
glands.  Primary  malignant  neoplasms  of  the  trachea  or  bronchus 
have  not  infrequently  been  diagnosticated  by  bronchoscopy. 
Peritracheal  or  peribronchial  malignancy  may  produce  a  compres- 
sive stenosis  covered  with  normal  mucosa.  Endoscopically,  the 
wall  is  seen  to  bulge  in  from  one  side  causing  a  crescentic 
picture,  or  compression  of  opposite  walls  may  cause  a  "scabbard" 
or  pear  shaped  lumen.  Endotracheal  and  endobronchial  malig- 
nancy ulcerate  early,  and  are  characterized  by  the  bronchoscopic 
view  of  a  bleeding  mass  of  fungating  tissue  bathed  in  pus  and 
secretion,  usually  foul.  The  diagnosis  in  these  cases  rests  upon 
the  exclusion  of  lues,  and  is  rendered  certain  by  the  removal  of  a 
specimen  for  biopsy.  Sarcoma  and  carcinoma  of  the  thyroid 
when  perforating  the  trachea  may  become  pedunculated.  In 
such  cases  aberrant  non-pathologic  thyroid  must  be  excluded  by 
biopsy.  Endothelioma  of  the  trachea  or  bronchus  may  also 
assume  a  pedunculated  form,  but  is  more  often  sessile. 

Treatment. — Pedunculated  malignant  growths  are  readily 
removed  with  snare  or  punch  forceps.  Cure  has  resulted  in  one 
case  of  the  author  following  bronchoscopic  removal  of  an  endo- 
thelioma from  the  bronchus;  and  a  limited  carcinoma  of  the  bron- 
chus has  been  reported  cured  by  bronchoscopic  removal,  with 
cauterization  of  the  base.  Most  of  the  cases,  however,  will  be 
subjects    for   palliative    tracheotomy   and   radium    therapy.     It 

will  be  found  necessary  in  many  of  the  cases  to  employ  the  author's 

214 


MALIGNANT    GROWTHS    OF    THE    TRACHEA  215 

long,  cane-shaped  tracheal  cannula  (Fig.  104,  A),  in  order  to  pipe 
the  air  down  to  one  or  both  bronchi  past  the  projecting  neoplasm. 

It  has  recently  been  demonstrated  that  following  the  intravenous 
injection  of  a  suspension  of  the  insoluble  salt,  radium  sulphate, 
that  the  suspended  particles  are  held  in  the  capillaries  of  the  lung 
for  a  period  of  one  year.  Intravenous  injections  of  a  watery 
suspension,  and  endobronchial  injections  of  a  suspension  of  radium 
sulphate  in  oil,  have  had  definite  beneficial  action.  While  as  yet, 
no  relatively  permanent  cures  of  pulmonary  malignancy  have  been 
obtained,  the  amelioration  and  steady  improvement  noted 
in  the  technic  of  radium  therapy  are  so  encouraging  that  every 
inoperable  case  should  be  thus  treated,  if  the  disease  is  not  in  a 
hopelessly  advanced  stage. 

In  a  case  under  the  care  of  Dr.  Robert  M.  Lukens  at  the 
Bronchoscopic  Clinic,  a  primary  epithelioma  of  the  trachea  was 
retarded  for  2  years  by  the  use  of  radium  applied  by  Dr.  William 
S.  Newcomet,  radium-therapist,  and  Miss  Katherine  E.  Schaeffer, 
technician. 


CHAPTER  XXVII 
MALIGNANT  DISEASE  OF  THE  ESOPHAGUS 

Cancer  of  the  esophagus  is  a  more  prevalent  disease  than  is 
commonly  thought.  In  the  male  it  usually  develops  during  the 
fourth  and  fifth  decades  of  life.  There  is  in  some  cases  the  history 
of  years  of  more  or  less  habitual  consumption  of  strong  alcoholic 
liquors.  In  the  female  the  condition  often  occurs  at  an  earlier 
age  than  in  the  male,  and  tends  to  run  a  more  protracted  course, 
preceeded  in  some  cases  by  years  of  precancerous  dysphagia. 

Squamous-celled  epithelioma  is  the  most  frequent  type  of 
neoplasm.  In  the  lower  third  of  the  esophagus,  cylindric  cell 
carcinoma  may  be  found  associated  with  a  like  lesion  in  the  stomach. 
Sarcoma   of   the   esophagus  is   relatively  rare    (Bibliography  i, 

p.  449)- 

The  sites  of  the  lesion  are  those  of  physiologic  narrowing  of 
the  esophagus.  The  middle  third  is  most  frequently  involved; 
and  the  lower  third,  near  the  cardia,  comes  next  in  frequency. 
Cancer  of  the  lower  third  of  the  esophagus  preponderates  in  men, 
while  cancer  of  the  upper  orifice  is,  curiously,  more  prevalent  in 
women.  The  lesion  is  usually  single,  but  multiple  lesions,  result- 
ing from  implantation  metastases  have  been  observed  (Bibliog- 
raphy I,  p.  391) .  Bronchoesophageal  fistula  from  extension  is  not 
uncommon. 

Symptoms. — Malignant  disease  of  the  esophagus  is  rarely  seen 

early,  because  of  the  absence,  or  mildness,  of  the  symptoms. 

Dysphagia,  the  one  common  symptom  of  all  esophageal  disease, 

is  often  ignored  by  the  patient  until  it  becomes  so  marked  as  to 

prevent  the  taking  of  solid  food ;  therefore,  the  onset  may  have  the 

similitude  of  abruptness.     Any  well  masticated  solid  food  can  be 

216 


MALIGNANT   DISEASE    OF    THE   ESOPHAGUS  21 7 

swallowed  through  a  lumen  5  millimeters  in  diameter.  The 
inability  to  maintain  the  nutrition  is  evidenced  by  loss  of  weight 
and  the  rapid  development  of  cachexia.  When  the  stenosis 
becomes  so  severe  that  the  fluid  intake  is  limited,  rapid  decline 
occurs  from  water  starvation.  Pain  is  usually  a  late  symptom  of 
the  disease.  It  may  be  of  an  aching  character  and  referred  to  the 
vertebral  region  or  to  the  neck;  or  it  may  only  accompany  the 
act  of  swallowing.  Blood-streaked,  regurgitated  material,  and 
the  presence  of  odor,  are  late  manifestations  of  ulceration  and 
secondary  infection.  In  some  cases,  constant  oozing  of  blood 
from  the  ulcerated  area  adds  greatly  to  the  cachexia.  If  the  recur- 
rent laryngeal  nerves  are  involved,  unilateral  or  bilateral  paralysis 
of  the  larynx  may  complicate  the  symptoms  by  cough,  dyspnea, 
aphonia,  and  possibly  septic  pneumonia. 

Diagnosis. — It  has  been  estimated  that  70  per  cent  of  stenoses 
of  the  esophagus  in  adults  are  malignant  in  nature.  This  should 
stimulate  the  early  and  careful  investigation  of  every  case  of 
dysphagia.  When  all  cases  of  persistent  dysphagia,  however 
slight,  are  endoscopically  studied,  precancerous  lesions  may  be 
discovered  and  treated,  and  the  limited  maHgnancy  of  the  early 
stages  may  be  afforded  surgical  treatment  while  yet  there  is 
hope  of  complete  removal.  Luetic  and  tuberculous  ulceration 
of  the  esophagus  are  to  be  eliminated  by  suitable  tests,  supple- 
mented in  rare  instances  by  biopsy.  Aneurysm  of  the  aorta  must 
in  all  cases  of  dysphagia  be  excluded,  for  the  dilated  aorta  may  be 
the  sole  cause  of  the  condition,  and  its  presence  contraindicates 
esophagoscopy  because  of  the  liability  of  rupture.  Foreign  body 
is  to  be  excluded  by  history  and  roentgenographic  study.  Spas- 
modic stenosis  of  the  esophagus  may  or  may  not  have  a  malignant 
origin.  Esophagoscopy  and  removal  of  a  specimen  for  biopsy 
renders  the  diagnosis  certain.  It  is  to  be  especially  remembered, 
however,  that  it  is  very  unwise  to  bite  through  normal  mucosa 


2l8  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

for  the  purpose  of  taking  a  specimen  from  a  periesophageal  growth. 
Fungations  and  polypoid  protuberances  afford  safe  opportunities 
for  the  removal  of  specimens  of  tissue. 

The  esophagoscopic  appearances  of  malignant  disease,  varying 
with  the  stage  and  site  of  origin  of  the  growth,  may  present  as 
follows: — 

1.  Submucosal  infiltration  covered  by  perfectly  normal  mem- 
brane, usually  associated  with  more  or  less  bulging  of  the  esopha- 
geal wall,  and  very  often  with  hardness  and  infiltration. 

2.  Leucoplakia. 

3.  Ulceration  projecting  but  little  above  the  surface  at  the 
edges. 

4.  Rounded  nodular  masses  grouped  in  mulberry-like  form, 
either  dark  or  light  red  in  color. 

5.  Polypoid  masses. 

6.  Cauliflower  fungations. 

In  considering  the  esophagoscopic  appearances  of  cancer,  it 
is  necessary  to  remember  that  after  ulceration  has  set  in,  the 
cancerous  process  may  have  engrafted  upon  it,  and  upon  its 
neighborhood,  the  results  of  inflammation  due  to  the  mixed  infec- 
tions. Cancer  invading  the  wall  from  without  may  for  a  long 
time  be  covered  with  perfectly  normal  mucous  membrane.  The 
significant  signs  at  this  early  stage  are: 

1.  Absence  of  one  or  more  of  the  normal  radial  creases  between 
the  folds. 

2.  Asymmetry  of  the  inspiratory  enlargement  of  lumen. 

3.  Sensation  of  hardness  of  the  wall  on  palpation  with  the 
tube. 

4.  The  involved  wall  will  not  readily  be  made  to  wrinkle  when 
pushed  upon  with  the  tube  mouth. 

In  all  the  later  forms  of  lesions  the  two  characteristics  are  (a) 
the  readiness  with  which  oozing  of  blood  occurs;  and  (b)  the  sense 


MALIGNANT    DISEASE    OF    THE    ESOPHAGUS  219 

of  rigidity,  or  fixation,  of  the  involved  area  as  palpated  with  the 
esophagoscope,  in  contrast  to  the  normally  supple  esophageal 
wall.  Esophageal  dilatation  above  a  malignant  lesion  is  rarely 
great,  because  the  stenosis  is  seldom  severely  obstructive  until 
late  in  the  course  of  the  disease. 

Treatment. — The  present  loo  per  cent  mortality  in  cancer  of 
the  esophagus  will  be  lowered  and  a  certain  percentage  of  surgical 
cures  will  be  obtained  when  patients  with  esophageal  symptoms 
are  given  the  benefit  of  early  esophagoscopic  study.  The  relief 
or  circumvention  of  the  dysphagia  requires  early  measures  to 
prevent  food  and  water  starvation.  Bouginage  of  a  malignant 
esophagus  to  increase  temporarily  the  size  of  the  stenosed  lumen 
is  of  questionable  advisability,  and  is  attended  with  the  great  risk 
of  perforating  the  weakened  esophageal  wall. 

Esophageal  intubation  may  serve  for  a  time  to  delay  gastros- 
tomy but  it  cannot  supplant  it,  nor  obviate  the  necessity  for  its 
ultimate  performance.  The  Charters-Symonds  or  Guisez  esopha- 
geal intubation  tube  is  readily  inserted  after  drawing  the  larynx 
forward  with  the  laryngoscope.  The  tube  must  be  changed 
every  week  or  two  for  cleaning,  and  duplicate  tubes  must  be  ready 
for  immediate  reinsertion.  Eventually,  a  smaller,  and  then  a  still 
smaller  tube  are  needed,  until  finally  none  can  be  introduced; 
though  in  some  cases  the  tube  can  be  kept  in  the  soft  mass  of 
fungations  until  the  patient  has  died  of  hemorrhage,  exhaustion, 
complications  or  intercurrent  disease. 

Gastrostomy  is  always  indicated  as  the  disease  progresses,  and 
it  should  be  done  before  nutrition  is  greatly  impaired.  Surgeons 
often  hesitate  thus  to  "operate  on  an  inoperable  case;"  but  it 
must  be  remembered  that  no  one  should  be  allowed  to  die  of 
hunger  and  thirst.  The  operation  should  be  done  before  inanition 
has  made  serious  inroads.  As  in  the  case  of  tracheotomy,  we 
always  preach  doing  it  early,  and  always  do  it  late.     If  postponed 


2  20  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

too  long,  water  starvation  may  proceed  so  far  that  the  patient 
will  not  recover,  because  the  water-starved  tissues  will  not  take 
up  water  put  in  the  stomach. 

Radiotherapy. — Radium  and  the  therapeutic  roentgenray  are 
today  our  only  effective  means  of  retarding  the  progress  of  eso- 
phageal malignant  neoplasms.  No  permanent  cures  have  been 
reported,  but  marked  temporary  improvement  in  the  swallowing 
function  and  prolongation  of  life  have  been  repeatedly  observed. 
The  combination  of  radium  treatment  applied  within  the  esopha- 
geal lumen  and  the  therapeutic  roentgenray  through  the  chest 
wall,  has  retarded  the  progress  of  some  cases. 

The  dosage  of  radium  or  the  therapeutic  ray  must  be  deter- 
mined by  the  radiologist  for  the  particular  individual  case;  its 
method  of  application  should  be  decided  by  consultation  of  the 
radiologist  and  the  endoscopist.  Two  fundamental  points  are  to 
be  considered,  however.  The  radium  capsule,  if  applied  within 
the  esophagus,  should  be  so  screened  that  the  soft,  irritating,  beta 
rays,  and  the  secondary  rays,  are  both  filtered  out  to  prevent 
sloughing  of  the  esophageal  mucosa.  The  dose  should  be  large 
enough  to  have  a  lethal  effect  upon  the  cancer  cells  at  the  peri- 
phery of  the  growth  as  well  as  in  the  center.  If  the  dose  be  insuffi- 
cient, development  of  the  cells  at  the  outside  of  the  growth  is 
stimulated  rather  than  inhibited.  It  is  essential  that  the  radium 
capsule  be  accurately  placed  in  the  center  of  the  malignant  stric- 
tured  area  and  this  can  be  done  only  by  visual  control  through  the 
esophagoscope  (Fig.  95). 

Drs.  Henry  K.  Pancoast,  George  E.  Pfahler  and  William  S. 
Newcomet  have  obtained  very  satisfactory  palliative  effects  from 
the  use  of  radium  in  esophageal  cancer. 


CHAPTER  XXVIII 
DIRECT  LARYNGOSCOPY  IN  DISEASES  OF  THE  LARYNX 

The  diagnosis  of  laryngeal  disease  in  young  children,  impossible 
with  the  mirror,  has  been  made  easy  and  precise  by  the  develop- 
ment of  direct  laryngoscopy.  No  anesthetic,  local  or  general, 
should  be  used,  for  the  practised  endoscopist  can  complete  the 
examination  within  a  minute  of  time  and  without  pain  to  the 
patient.  The  technic  for  doing  this  should  be  acquired  by  every 
laryngologist.  Anesthesia  is  absolutely  contraindicated  because 
of  the  possibility  of  the  presence  of  diphtheria,  and  especially 
because  of  the  dyspnea  so  frequently  present  in  laryngeal  disease. 
To  attempt  general  anesthesia  in  a  dyspneic  case  is  to  invite  dis- 
aster (see  Tracheotomy).  It  is  to  be  remembered  that  coughing 
and  straining  produce  an  engorgement  of  the  laryngeal  mucosa, 
so  that  the  first  glance  should  include  an  estimation  of  the  color 
of  the  mucosa,  which,  as  a  result  of  the  engorgement,  deepens 
with  the  prolongation  of  the  direct  laryngoscopy. 

Chronic  subglottic  edema,  often  the  result  of  perichondritis, 
may  require  linear  cauterization  at  various  times,  to  reduce  its 
bulk,  after  the  underlying  cause  has  been  removed. 

Perichondritis  and  abscess,  and  their  sequelae  are  to  be  treated 
on  the  accepted  surgical  precepts.  They  may  be  due  to  trauma, 
lues,  tuberculosis,  enteric  fever,  pneumonia,  influenza,  etc. 

Tuberculosis  of  the  larynx  calls  for  conservatism  in  the  applica- 
tion of  surgery.  Ulceration  limited  to  the  epiglottis  may  justify 
amputation  of  the  projecting  portion  or  excision  of  only  the  ulcerated 
area.  In  either  case,  rapid  healing  may  be  expected,  and  relief 
from  the  odynphagia  is  sometimes  prompt.     Amputation  of  the 


22  2  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

epiglottis  is,  however,  not  to  be  done  if  ulceration  in  other  portions 
of  the  larynx  coexist.  The  removal  of  tuberculomata  is  sometimes 
indicated,  and  the  excision  of  limited  ulcerative  lesions  situated 
elsewhere  than  on  the  epiglottis  may  be  curative.  These  measures 
as  well  as  the  galvanocautery  are  easily  executed  by  the  facile 
operator;  but  their  advisability  should  always  be  considered  from  a 
conservative  viewpoint.  They  are  rarely  justifiable  until  after 
months  of  absolute  silence  and  a  general  antituberculous  regime 
have  failed  of  benefit. 

Galvano puncture  for  laryngeal  tuberculosis  has  yielded  excellent 
results  in  reducing  the  large  pyriform  edematous  swellings  of 
the  aryepiglottic  folds  when  ulceration  has  not  yet  developed. 
Deep  punctures  at  nearly  a  white  heat,  made  perpendicular  to  the 
surface,  are  best.  Care  must  be  exercised  not  to  injure  the  crico- 
arytenoid joint.  Fungating  ulcerations  may  in  some  cases  be 
made  to  cicatrize  by  superficial  cauterization.  Excessive  reactions 
sometimes  follow,  so  that  a  light  application  should  be  made 
at  the  first  treatment. 

Congenital  laryngeal  stridor  is  produced  by  an  exaggeration  of 
the  infantile  type  of  larynx.  The  epiglottis  will  be  found  long 
and  tapering,  its  lateral  margins  rolled  backward  so  as  to  meet 
and  form  a  cylinder  above.  The  upper  edges  of  the  aryepiglottic 
folds  are  approximated,  leaving  a  narrow  chink.  The  lack  of 
firmness  in  these  folds  and  the  loose  tissue  in  the  posterior  portion 
of  the  larynx,  favors  the  drawing  inward  of  the  laryngeal  aperture 
by  the  inspiratory  blast.  The  vibration  of  the  margins  of  this 
aperture  produces  the  inspiratory  stridor.  Diagnosis  is  quickly 
made  by  the  inspection  of  the  larynx  with  the  infant  diagnostic 
laryngoscope.  No  anesthetic,  general  or  local,  is  needed.  Stridor- 
ous  respiration  may  also  be  due  to  the  presence  of  laryngeal 
papillomata,  laryngeal  spasm,  thymic  compression,  congenital 
web,  or  an  abnormal  inspiratory  bulging  into  the  trachea  of  the 


DIRECT    LARYNGOSCOPY    IN    DISEASES    OF    THE    LARYNX        223 

posterior  membranous  tracheo-esophageal  wall.  The  term  "con- 
genital laryngeal  stridor"  should  be  limited  to  the  first  described 
condition  of  exaggerated  infantile  larynx. 

Treatment  of  congenital  laryngeal  stridor  should  be  directed  to 
the  relief  of  dyspnea,  and  to  increasing  the  nutrition  and  develop- 
ment of  the  infant.  The  insertion  of  a  bronchoscope  will 
temporarily  relieve  an  urgent  dyspneic  attack  precipitated  by  exami- 
nation; but  this  rarely  happens  if  the  examination  is  not  unduly 
prolonged.  Tracheotomy  may  be  needed  to  prevent  asphyxia 
or  exhaustion  from  loss  of  sleep;  but  very  few  cases  require  any- 
thing but  attention  to  nutrition  and  hygiene.  Recovery  can  be 
expected  with  development  of  the  laryngeal  structures. 

Congenital  webs  of  the  larynx  require  incision  or  excision,  or 
perhaps  simply  bouginage.  Congenital  goiter  and  congenital 
laryngeal  paralysis,  both  of  which  may  cause  stertorous  breathing, 
are  considered  in  connection  with  other  forms  of  stenosis  of  the 
air  passages. 

Aphonia  due  to  cicatricial  webs  of  the  larynx  may  be  cured  by 
plastic  operations  that  reform  the  cords,  with  a  clean,  sharp  an- 
terior commissure,  which  is  a  necessity  for  clear  phonation.  The 
laryngeal  scissors  and  the  long  slender  punch  are  often  more  useful 
for  these  operations  than  the  knife. 


CHAPTER  XXIX 

BRONCHOSCOPY  IN   DISEASES   OF   THE   TRACHEA   AND 

BRONCHI 

The  indications  for  bronchoscopy  in  disease  are  becoming  increas- 
ingly numerous.     Among  the  more  important  may  be  mentioned: 

1.  Bronchiectasis. 

2.  Chronic  pulmonary  abscess. 

3.  Unexplained  dyspnea. 

4.  Dyspnea  unrelieved  by  tracheotomy  calls  for  bronchoscopic 
search  for  deeper  obstruction. 

5.  Paralysis  of  the  recurrent  laryngeal  nerve,  the  cause  of  which 
is  not  positively  known. 

6.  Obscure  thoracic  disease. 

7.  Unexplained  hemoptysis.  , 

8.  Unexplained  cough. 

9.  Unexplained  expectoration. 

Contraindications  to  bronchoscopy  in  disease  do  not  exist  if  the 
bronchoscopy  is  really  needed.  Serious  organic  disease  such  as 
aneurysm,  hypertension,  advanced  cardiac  disease,  might  render 
bronchoscopy  inadvisable  except  for  the  removal  of  foreign  bodies. 

Bronchoscopic  Appearances  in  Disease. — The  first  look  should 
note  the  color  of  the  bronchial  mucosa,  due  allowance  being  made 
for  the  pressure  of  tubal  contact,  secretions,  and  the  engorgement 
incident  to  continued  cough.  The  carina  trachealis  normally 
moves  slowly  forward  as  well  as  downward  during  deep  inspiration, 
returning  quickly  during  expiration.  Impaired  movement  of  the 
carina  ^indicates  peritracheal  and  peribronchial  pathology,  the 
fixation  being  greatest  in  advanced  cancer.     In  children  and  in 

the  smaller  tubes  of  the  adult,  the  lengthening  and  dilatation  of 

224 


DISEASES    OF    THE    TRACHEA    AND   BRONCHI  225 

the  bronchi  during  inspiration,  and  their  shortening  and  contrac- 
tion during  expiration  are  readily  seen. 

Anomalies  of  the  Tracheobronchial  Tree. — Tracheobronchial 
anomalies  are  relatively  rare.  Congenital  esophagotracheal  and 
esophagobronchial  fistulae  are  occasionally  seen,  and  cases  of 
cervicotracheal  fistulae  have  been  reported.  Congenital  webs  and 
diverticula  of  the  trachea  are  cited  infrequently.  Laryngoptosis 
and  deviation  of  the  trachea  may  be  congenital.  Substernal 
goitre,  aneurysm,  malignant  growths,  and  various  mediastinal 
adenopathies  may  displace  the  trachea  from  its  normal  course. 
The  emphysematous  chest  fixed  in  the  deep  voluntary  inspiratory 
position  produces  in  some  cases  an  elevation  of  the  superior 
thoracic  aperture  simulating  laryngoptosis  (Bibliography  i,  pp. 
468,  594). 

Compression  Stenosis  of  the  Trachea  and  Bronchi. — Compression 
of  the  trachea  is  most  commonly  caused  by  goiter,  substernal  or 
cervical,  aneurysm,  malignancy,  or,  in  children,  by  enlarged  thy- 
mus. Less  frequently,  enlarged  mediastinal  tuberculous,  leuke- 
mic, leutic  or  Hodgkin's  glands  compress  the  airway.  The  left 
bronchus  may  be  stenosed  by  pressure  from  a  hypertrophied 
cardiac  auricle.  Compression  stenosis  of  the  trachea  associated 
with  pulmonary  emphysema  accounts  for  the  dyspnea  during 
attacks  of  coughing. 

The  endoscopic  picture  of  compression  stenosis  is  that  of  an 
elliptical  or  scabbard-shaped  lumen  when  the  bronchus  is  at  rest 
or  during  inspiration.  Concentric  funnel-like  compression  sten- 
osis, while  rare,  may  be  produced  by  annular  growths. 

Treatment  of  Compression  Stenoses  of  the  Trachea. — If  the 
thymus  be  at  fault,  rapid  amelioration  of  symptoms  follows 
roentgenray  or  radium  therapy.  Tracheotomy  and  the  insertion 
of  the  long  cane-shaped  cannula  (Fig.  104)  past  the  compressed 
area  is  required  in  the  cases  caused  by  conditions  less  amenable 
to  treatment  than  thymic  enlargement.     Permanent  cure  depends 

15 


2  26  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

upon  the  removability  of  the  compressive  mass.  Should  the 
bronchi  be  so  compressed  by  a  benign  condition  as  to  prevent 
escape  of  secretions  from  the  subjacent  air  passages,  bronchial 
intubation  tubes  may  be  inserted,  and,  if  necessary,  worn  con- 
stantly. They  should  be  removed  weekly  for  cleansing  and 
oftener  if  obstructed. 

Influenzal  Laryngotracheohronchitis. — Influenzal  infection,  not 
always  by  the  same  organism,  sweeps  over  the  population,  attack- 
ing the  air  passages  in  a  violent  and  quite  characteristic  way. 
Bronchoscopy  shows  the  influenzal  infection  to  be  characterized 
by  intense  reddening  and  swelling  of  the  mucosa.  In  some  cases 
the  swelling  is  so  great  as  to  necessitate  tracheotomy,  or  intuba- 
tion of  the  larynx;  and  if  the  edema  involve  the  bronchi,  occlusion 
may  be  fatal.  Hemorrhagic  spots  and  superficial  erosions  are 
commonly  seen,  and  a  thick,  tenacious  exudate,  difficult  of  expec- 
toration, lies  in  patches  in  the  trachea.  Infants  may  asphyxiate 
from  accumulation  of  this  secretion  which  they  are  unable  to 
expel.  The  differential  diagnosis  from  diphtheria  is  sometimes 
difficult.  The  absence  of  true  membrane  and  the  failure  to  find 
diphtheria  bacilli  in  smears  taken  from  the  trachea  are  of  aid 
but  are  not  infallible.  In  doubtful  cases,  the  administration  of 
diphtheria  antitoxin  is  a  wise  precaution  pending  the  establish- 
ment of  a  definite  diagnosis.  The  pseudomembrane  sometimes 
present  in  influenzal  tracheobronchitis  is  thinner  and  less  pulpy 
than  that  of  the  earlier  stages  of  diphtheria.  The  casts  of  the  later 
stages  do  not  occur  in  influenzal  tracheobronchitis  (Bibliography 
I,  p.  480). 

Edematous  Tracheobronchitis . — This  is  chiefly  observed  in 
children.  The  most  frequently  encountered  form  is  the  epidemic 
disease  to  which  the  name  "  Influenza  "  has  been  given  {q.v.  supra) . 
The  only  noticeable  difference  between  the  epidemic  and  the 
sporadic  cases  is  in  the  more  general  susceptibility  to  the  infective 
agent,  which  gives  the  influenzal  form  an  appearance  of  being  more 


DISEASES    OF    THE    TRACHEA    AND   BRONCHI  227 

virulently  infective.  Possibly  the  sporadic  form  is  simply  the 
attack  of  children  not  immunized  by  a  previous  attack  during  an 
epidemic. 

There  is  another  form  of  edematous  tracheobronchitis  often 
of  great  severity  and  grave  prognosis,  that  results  from  the  aspira- 
tion of  irritating  liquids  or  vapors,  or  of  certain  organic  substances 
such  as  peanut  kernels,  watermelon  seeds,  etcetera.  Tracheotomy 
should  be  done  if  marked  dyspnea  be  present.  Secretions  can 
then  be  easily  removed  and  medication  in  the  form  of  oily  solutions 
be  instilled  at  will  into  the  trachea.  In  the  Bronchoscopic  Clinic 
many  children  have  been  kept  alive  for  days,  and  their  lives 
finally  saved  by  aspiration  of  thick,  tough,  sometimes  clotted  and 
crusted  secretions,  with  the  aspirating  tube  (Fig.  lo).  It  is  better 
in  these  cases  not  to  pass  the  bronchoscope  repeatedly.  If,  how- 
ever, evidences  of  obstruction  remain,  after  aspiration,  it  is 
necessary  to  see  the  nature  of  the  obstruction  and  relieve  it  by 
removal,  dilatation,  or  bronchial  intubation  as  the  case  may  require. 
It  is  all  a  matter  of  "plumbing"  i.e.,  clearing  out  the  "pipes," 
and  maintaining  a  patulous  airway. 

Tracheobronchial  Diphtheria. — Urgent  dyspnea  in  diphtheria 
when  no  membrane  and  but  slight  lessening  of  the  laryngeal 
airway  is  seen,  calls  for  bronchoscopy.  Many  lives  have  been 
saved  by  the  bronchoscopic  removal  of  membrane  obstructing  the 
trachea  or  bronchi.  In  the  early  stages,  pulpy  masses  looking 
like  "mother"  of  vinegar  are  very  obstructive.  Later  casts  of 
membrane  may  simulate  foreign  bodies.  The  local  application 
of  diphtheria  antitoxin  to  the  trachea  and  bronchi  has  also  been 
recommended.  A  preparation  free  from  a  chemical  irritant 
should  be  selected. 

Abscess  of  the  Lung. — If  of  foreign-body  origin,  pulmonary 
abscess  almost  invariably  heals  after  the  removal  of  the  object  and 
a  regime  of  fresh  air  and  rest,  without  local  measures  of  any  kind. 


2  28  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

Acute  pulmonary  abscess  from  other  causes  may  require  broncho- 
scopic  drainage  and  gentle  dilatation  of  the  swollen  and  narrowed 
bronchi  leading  to  it.  Some  of  these  bronchi  are  practically 
fistulae.  Obstructive  granulations  should  be  removed  with 
crushing,  not  biting  forceps.  The  regular  foreign-body  forceps 
are  best  for  this  purpose.  Caution  should  be  used  as  to  removal 
of  the  granulations  with  which  the  abscess  "cavity"  is  filled  in 
chronic  cases.  The  term  ''abscess"  is  usually  loosely. applied  to 
the  condition  of  drowned  lung  in  which  the  pus  has  accumulated 
in  natural  passages,  and  in  which  there  is  neither  a  new  wall  nor 
a  breaking  down  of  normal  walls.  Chronic  lung-abscess  is  often 
successfully  treated  by  weekly  bronchoscopic  lavage  with  20  cc. 
or  more  of  a  warm,  normal  salt  solution,  a  i  :iooo  watery  potassium 
permanganate  solution,  or  a  weak  iodine  solution  as  in  the  follow- 
ing formula: 

I^.     Monochlorphenol  (Merck) .12 

Lugol's  solution 8 .  00 

Normal  salt  solution 500. 

Perhaps  the  best  procedure  is  to  precede  medicinal  applica- 
tions by  the  clearing  out  of  the  purulent  secretions  by  aspiration 
with  the  aspirating  bronchoscope  and  the  independent  aspirating 
tube,  the  latter  being  inserted  into  passages  too  small  to  enter  with 
the  bronchoscope,  and  the  endobronchial  instillation  of  from  10 
to  30  cc.  of  the  medicament.  The  following  have  been  used: 
Argyrol,  i  per  cent  watery  solution;  Silvol,  i  per  cent  watery 
solution;  Iodoform,  oil  emulsion  10  per  cent;  Guaiacol,  10  per 
cent  solution  in  parafhne  oil;  Gomenol,  20  per  cent  solution  in 
oil;  or  a  bismuth  subnitrate  suspension  in  oil.  Robert  M.  Lukens 
and  William  F.  Moore  of  the  Bronchoscopic  Clinic  report  excellent 
results  in  post-tonsillectomy  abscesses  from  one  tenth  of  one 
per  cent  phenol  in  normal  salt  solution  with  the  addition  of  2 


DISEASES    OF    THE    TRACHEA    AND   BRO^XHI  229 

per  cent  Lugol's  solution.  Chlorinated  solutions  are  irritating, 
and  if  used,  require  copious  dilution.  Liquid  petrolatum  with  a 
little  oil  of  eucalyptus  has  been  most  often  the  medium. 

Gangrene  of  the  Lung. — Pulmonary  gangrene  has  been  followed 
by  recovery  after  the  endobronchial  injection  of  oily  solutions 
of  gomenol  and  guaiacol  (Guisez).  The  injections  are  readily 
made  through  the  laryngoscope  without  the  insertion  of  a  bron- 
choscope. A  silk  woven  catheter  may  be  used  with  an  ordinary 
glass  syringe  or  a  long-nozzled  laryngeal  syringe,  or  a  broncho - 
scopic  syringe  may  be  used. 

Lung-mapping  by  a  roentgenogram  taken  promptly  after  the 
bronchoscopic  insufflation  of  bismuth  subnitrate  powder  or  the 
injection  of  a  suspension  of  bismuth  in  liquid  petrolatum  is 
advisable  in  most  cases  of  pulmonary  abscess  before  beginning  any 
kind  of  treatment. 

Bronchial  Stenosis. — Stenosis  of  one  or  more  bronchi  results 
at  times  from  cicatricial  contraction  following  secondary  infection 
of  leutic,  tuberculous  or  traumatic  lesions.  The  narrowing  result- 
ing from  foreign  body  traumatism  rarely  requires  secondary 
dilatation  after  the  foreign  body  has  been  removed.  Tuberculous 
bronchial  stenoses  rarely  require  local  treatment,  but  are  easily 
dilated  when  necessary.  Luetic  cicatricial  stenosis  may  require 
repeated  dilatation,  or  even  bronchial  intubation.  Endobronchial 
neoplasms  may  cause  a  subjacent  bronchiectasis,  and  superjacent 
stenosis;  the  latter  may  require  dilatation.  Cicatricial  stenoses 
of  the  bronchi  are  readily  recognizable  by  the  scarred  wall  and 
the  absence  of  rings  at  or  near  the  narrowing. 

Bronchiectasis. — In  most  cases  of  bronchiectasis  there  are 
strong  indications  for  a  bronchoscopic  diagnosis,  to  eliminate 
such  conditions  as  foreign  body,  cicatricial  bronchial  stenosis, 
or  endobronchial  neoplasm  as  etiologic  factors.  In  the  idiopathic 
types  considerable  benefit  has  resulted  from  the  endobronchial 


230  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

lavage  and  endobronchial  oily  injections  mentioned  under  lung 
abscess.  It  is  probable  that  if  bronchoscopic  study  were  carried 
out  in  every  case,  definite  causes  for  many  so-called  "idiopathic" 
cases  would  be  discovered.  Lung-mapping  as  elsewhere  herein 
explained  is  invaluable  in  the  study  of  bronchiectasis. 

Bronchial  asthma  affords  a  large  field  for  bronchoscopic  study. 
As  yet,  sufficient  data  to  afford  any  definite  conclusions  even  as 
to  the  endoscopic  picture  of  this  disease  have  not  been  accumulated. 
Of  the  cases  seen  in  the  Bronchoscopic  Clinic  some  showed  no 
abnormality  of  the  bronchi  in  the  intervals  between  attacks, 
others  a  chronic  bronchitis.  In  cases  studied  bronchoscopically 
during  an  attack,  the  bronchi  were  found  filled  with  bubbling 
secretions  and  the  mucosa  was  somewhat  cyanotic  in  color.  The 
bronchial  lumen  was  narrowed  only  as  much  as  it  would  be, 
with  the  same  degree  of  cough,  in  any  patient  not  subject  to 
asthma.  The  secretions  were  removed  and  the  attack  quickly 
subsided;  but  no  influence  on  the  recurrence  of  attacks  was 
observed.  It  is  essential  that  the  bronchoscopic  studies  be  made, 
as  were  these,  without  anesthesia,,  local  or  general,  for  it  is  known 
that  the  application  of  cocain  or  adrenalin  to  the  larynx,  or  even 
in  the  nose,  will,  with  some  patients,  stop  the  attack.  When  done 
without  local  anesthesia,  allowance  must  be  made  for  the  reaction 
to  the  presence  of  the  tube.  In  those  cases  in  which  other  means 
have  failed  to  give  relief,  the  endobronchial  application  of  novocain 
and  adrenalin,  orthoform,  propaesin  or  anesthesin  emulsion  may 
be  tried.  Cures  have  been  reported  by  this  treatment.  Argentic 
nitrate  applied  at  weekly  intervals  has  proven  very  efficient  in 
some  cases.  Associated  infective  disease  of  the  bronchial  mucosa 
brings  with  it  the  questions  of  immunity,  allergy,  anaphylaxis, 
and  vaccine  therapy;  and  the  often  present  defective  metabolism 
has  to  be  considered. 

Autodrownage. — Autodrownage  is  the  name  given  by  the  author 


DISEASES    OF    THE    TRACHEA   AND  BRONCHI  23 1 

to  the  drowning  of  the  patient  in  his  own  secretions.  Tracheo- 
bronchial secretions  in  excess  of  the  amount  required  to  moisten 
the  inspired  air,  become,  in  certain  cases,  a  mechanical  menace  to 
life,  unless  removed.  The  cough  reflex,  forced  expiration,  and 
ciliary  action,  normally  remove  the  excess.  When  these  mechan- 
isms are  impaired,  as  in  profound  asthenia,  laryngeal  paralysis, 
laryngeal  or  tracheal  stenosis,  etc. ;  and  especially  when  in  addition 
to  a  mild  degree  of  glottic  stenosis  or  impaired  laryngeal  mobility, 
the  secretions  become  excessive,  the  accumulation  may  literally 
drown  the  patient  in  his  own  secretions.  This  is  illustrated  fre- 
quently in  influenza  and  arachidic  bronchitis.  Infants  cannot 
expectorate,  and"  their  cough  reflex  is  exceedingly  ineffective  in 
raising  secretion  to  the  pharynx;  furthermore  they  are  easily 
exhausted  by  bechic  efforts;  so  that  age  may  be  cited  as  one 
of  the  most  frequent  etiologic  factors  in  the  condition  of 
autodrownage.  Bronchoscopic  sponge-pumping  (q.v.)  and  bron- 
choscopic  aspiration  are  quite  efficient  and  can  save  any  patient 
not  afflicted  with  conditions  that  are  fatal  by  other  pathologic 
processes. 

Lues  of  the  Tracheobronchial  Tree. — Compared  to  laryngeal 
involvement,  syphilis  of  the  tracheobronchial  tree  is  relatively 
rare.  The  lesions  may  be  gummatous,  ulcerative,  or  inflammatory, 
or  there  may  be  compressive  granulomatous  masses.  Hemoptysis 
may  have  its  origin  from  a  luetic  ulceration.  Excision  of  funga- 
tions  or  of  a  portion  of  the  margin  of  the  ulceration  for  biopsy  is 
advisable.  The  Wassermann  and  therapeutic  tests,  and  the 
elimination  of  tuberculosis  will  be  required  for  confirmation. 
Luetic  stenoses  are  referred  to  above. 

Tuberculosis  of  the  Tracheobronchial  Tree. — The  bronchoscopic 
study  of  tuberculosis  is  very  interesting,  but  only  a  few  cases 
justify  bronchoscopy.  The  subglottic  infiltrations  from  exten- 
sions of  laryngeal  disease  are  usually  of  edematous  appearance, 


232  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

though  they  are  much  more  firm  than  in  ordinary  inflammatory 
edema.  Ulcerations  in  this  region  are  rare,  except  as  direct 
extensions  of  ulceration  above  the  cord.  The  trachea  is  relatively 
rarely  involved  in  tuberculosis,  but  we  may  have  in  the  trachea  the 
pale  swelling  of  the  early  stage  of  a  perichondritis,  or  the  later 
ulceration  and  all  the  phenomena  following  the  mixed  pyogenic 
infections.  These  same  conditions  may  exist  in  the  bronchi. 
In  a  number  of  instances,  the  entire  lumen  of  the  bronchus  was 
occluded  by  cheesy  pus  and  debris  of  a  peribronchial  gland  which 
had  eroded  through.  As  a  rule,  the  mucosa  of  tuberculosis  is 
pale,  and  the  pallor  is  accentuated  by  the  rather  bluish  streak  of 


Fig.  96. — The  author's  tampons  for  pulmonary  hemostasis  by  bronchoscopic  tam- 
ponade.    The  folded  gauze  is  10  cm.  long;  the  braided  silk  cord  60  cm.  long. 

vessels,  where  these  are  visible.  Erosion  through  of  peri-bronchial 
or  peri-tracheal  lymph  masses  may  be  associated  with  granulation 
tissue,  usually  of  pale  color,  but  occasionally  reddish;  and  some- 
times oozing  of  blood  is  noticed.  A  most  common  picture  in 
tuberculosis  is  a  broadening  of  the  carina,  which  may  be  so  marked 
as  to  obliterate  the  carina  and  to  bulge  inward,  producing  de- 
formed lumina  in  both  bronchi.  Sometimes  the  lumina  are 
crescentic,  the  concavity  of  the  crescent  being  internal,  that  is, 
toward  the  median  line.  Absence  of  the  normal  anterior  and 
downward  movement  of  the  carina  on  deep  inspiration  is  almost 
pathognomonic  of  a  mass  at  the  bifurcation,  and  such  a  mass  is 
usually  tuberculous,  though  it  may  be  malignant,  and,  very  rarely, 
luetic.     The  only  lesion  visible  in  a  tuberculous  case  may    be 


DISEASES    OF    THE    TRACHEA    AND   BRONCHI  233 

cicatrices  from  healed  processes.  In  a  number  of  cases  there  has 
been  a  discharge  of  pus  coming  from  the  upper-lobe  bronchus. 

Hemoptysis. — In  cases  not  demonstrably  tuberculous,  hemop- 
tysis may  require  bronchoscopic  examination  to  determine  the 
origin.  Varices  or  unsuspected  luetic,  malignant,  or  tuberculous 
lesions  may  be  found  to  be  the  cause.  It  is  mechanically  easy  to 
pack  off  one  bronchus  with  the  author's  packs  (Fig.  96)  introduced 
through  the  bronchoscope,  but  the  advisability  of  doing  so  requires 
further  clinical  tests. 

Angioneurotic  Edema. — Angioneurotic  edema  manifests  itself 
by  a  pale  or  red  swollen  mucosa  producing  stenosis  of  the  lumen. 
The  temporary  character  of  the  lesion  and  its  appearance  in  other 
regions  confirm  the  diagnosis. 

Scleroma  of  the  trachea  is  characterized  by  infiltration  of  the 
tracheal  mucosa,  which  greatly  narrows  the  lumen.  The  infiltra- 
tion may  be  limited  in  area  and  produce  a  single  stricture,  or  it 
may  involve  the  entire  trachea  and  even  close  a  bronchial  orifice. 
Drying  and  crusting  of  secretions  renders  the  stenosis  still  more 
distressing.  This  disease  is  but  rarely  encountered  in  America 
but  is  not  infrequent  in  some  parts  of  Europe.  Treatment  con- 
sists in  the  prevention  of  crusts  and  their  removal.  Limited 
stenotic  areas  may  yield  to  bronchoscopic  bouginage.  Urgent 
dyspnea  calls  for  tracheotomy.  Radium  and  roentgenray  ther- 
apy have  been  advised,  and  cure  has  been  reported  by  intravenous 
salvarsan  treatment  (see  article  by  S.  Shelton  Watkins,  on 
Scleroma  in  Surg.  Gynecol,  and  Obst.,  July,  192 1,  p.  47). 

Atrophic  tracheitis,  with  symptoms  quite  similar  to  atrophic 
rhinitis  is  a  not  unusual  accompaniment  of  the  nasal  condition. 
It  may  also  exist  without  nasal  involvement.  On  tracheoscopy 
the  mucosa  is  thinned,  pale  and  dry,  and  is  covered  with  patches 
of  thick  mucilaginous  secretion  and  crusts.  Decomposition  of 
secretion    produces    tracheal    "ozena,"    while    the    accumulated 


234  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

crusts  give  rise  to  the  sensation  of  a  foreign  body  and  may  seri- 
ously interfere  with  respiration,  making  bronchoscopic  removal 
imperative.  The  associated  development  of  tracheal  nodular 
enchondromata  has  been  described.  The  internal  administration 
of  iodine  and  the  intratracheal  injection  of  bland  oily  solutions 
of  menthol,  guaiacol,  or  gomenol  are  helpful. 


CHAPTER  XXX 
DISEASES  OF  THE  ESOPHAGUS 

The  more  frequent  causes  of  the  one  common  symptom  of 
esophageal  disease,  dysphagia,  are  included  in  the  list  given  below. 
To  avoid  elaboration  and  to  obtain  maximum  usefulness  as  a 
reminder,  overlapping  has  not  been  eliminated. 

1.  Anomalies. 

2.  Esophagitis,  acute. 

3.  Esophagitis,  chronic. 

4.  Erosion. 

5.  Ulceration. 

6.  Trauma. 

7.  Stricture,  congenital. 

8.  Stricture,  spasmodic,  including  cramp  of  the  diaphragmatic  pinchcock. 

9.  Stricture,  inflammatory. 

10.  Stricture,  cicatricial. 

11.  Dilatation,  local. 

12.  Dilatation,  diffuse. 

13.  Diverticulum. 

14.  Compression  stenosis. 

15.  Mediastinal  tumor.  . 

16.  Mediastinal  abscess. 

17.  Mediastinal  glandular  mass. 

18.  Aneurysm. 

19.  Malignant  neoplasm. 

20.  Benign  neoplasm. 

21.  Tuberculosis. 

22.  Lues. 

23.  Actinomycosis. 

24.  Varix. 

25.  Angioneurotic  edema. 

26.  Hysteria. 

27.  Functional  antiperistalsis. 

28.  Paralysis. 

29.  Foreign  body  in  (a)  pharynx,  (b)  larynx,  (c)  trachea,  (d)  esophagus. 

235 


236  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

Diagnosis. — The  swallowing  function  can  be  studied  only  with 
the  fluoroscope;  esophagoscopy  for  diagnosis,  should  therefore 
always  be  preceded  by  a  fluoroscopic  study  of  deglutition  with  a 
barium  or  other  opaque  mixture  and  examination  of  the  thoracic 
organs  to  eliminate  external  pressure  on  the  esophagus  as  the 
cause  of  stenosis.  Complete  physical  examination  and  Wasser- 
mann  reaction  are  further  routine  preliminaries  to  any  esopha- 
goscopy. Special  laboratory  tests  are  done  as  may  be  indicated. 
The  physical  examination  is  meant  to  include  a  careful  examina- 
tion of  the  lips,  tongue,  palate,  pharynx,  and  a  mirror  examination 
of  the  larynx  when  age  permits. 

Indications  for  Esophagoscopy  in  Disease. — Any  persistent 
abnormal  sensation  or  disturbance  of  function  of  the  esophagus 
calls  for  esophagoscopy.  Vague  stomach  symptoms  may  prove 
to  be  esophageal  in  origin,  for  vomiting  is  often  a  complaint  when 
the  patient  really  regurgitates. 

Contraindications  to  Esophagoscopy. — In  the  presence  of 
aneurysm,  advanced  organic  disease,  extensive  esophageal  vari- 
cosities, acute  necrotic  or  corrosive  esophagitis,  esophagoscopy 
should  not  be  done  except  for  urgent  reasons,  such  as  the  lodg- 
ment of  a  foreign  body;  and  in  this  case  the  esophagoscopy  may 
be  postponed,  if  necessary,  unless  the  patient  is  unable  to  swallow 
fluids.  Esophagoscopy  should  be  deferred,  in  cases  of  acute 
esophagitis  from  swallowing  of  caustics,  until  sloughing  has  ceased 
and  healing  has  strengthened  the  weak  places.  The  extremes  of 
age  are  not  contraindications  to  esophagoscopy.  A  number  of 
newborn  infants  have  been  esophagoscoped  by  the  author;  and 
he  has  removed  foreign  bodies  from  patients  over  80  years  of 
age. 

Water  starvation  makes  the  patient  a  very  bad  surgical  subject, 
and  is  a  distinct  contraindication  to  esophagoscopy.  Water  must 
be  supplied  by  means  of  proctoclysis  and  hypodermoclysis  before 


DISEASES    OF    THE    ESOPHAGUS  237 

any  endoscopic  or  surgical  procedure  is  attempted.  If  the  esopha- 
geal stenosis  is  not  readily  and  quickly  remediable,  gastrostomy 
should  be  done  immediately.  Rectal  feeding  will  supply  water  for 
a  limited  time,  but  for  nutrient  purposes  rectal  alimentation  is 
dangerously  inefficient. 

Preliminary  examination  of  the  pharynx  and  larynx  with  tongue 
depressor  should  always  precede  esophagoscopy,  for  any  purpose, 
because  the  symptoms  may  be  due  to  laryngeal  or  pharyngeal 
disease  that  might  be  overlooked  in  passing  the  esophagoscope. 
A  high  degree  of  esophageal  stenosis  results  in  retention  in  the 
suprajacent  esophagus  of  the  fluids  which  normally  are  continually 
flowing  downward.  The  pyriform  sinuses  in  these  cases  are  seen 
with  the  laryngeal  mirror  to  be  filled  with  frothy  secretion  (Jack- 
son's sign  of  esophageal  stenosis)  and  this  secretion  may  sometimes 
be  seen  trickling  into  the  larynx.  This  overflow  into  the  larynx 
and  lower  air  passages  is  often  the  cause  of  pulmonary  symptoms, 
which  are  thus  strictly  secondary  to  the  esophageal  disease. 

ANOMALIES  OF  THE  ESOPHAGUS 

Congenital  esophagotracheal  fistulae  are  the  most  frequent  of 
the  embryonic  developmental  errors  of  this  organ.  Septic 
pneumonia  from  the  entrance  of  fluids  into  the  lungs  usually 
causes  death  within  a  few  weeks. 

Imperforate  esophagus  usually  shows  an  upper  esophageal 
segment  ending  in  a  blind  pouch.  A  lower  segment  is  usually 
present  and  may  be  connected  with  the  upper  segment  by  a 
fistula. 

Congenital  stricture  of  the  esophagus  may  be  single  or  multiple, 
and  may  be  thin  and  weblike,  or  it  may  extend  over  a  third  or 
more  of  the  length  of  the  esophagus.  It  may  not  become  manifest 
until  solids  are  added  to  the  child's  diet;  often  not  for  many 
months.     The  lodgment  of  an  unusually  large  bolus  of  unmasti- 


238  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

catecl  food  may  set  up  an  esophagitis  the  swelling  of  which  may 
completely  close  the  lumen  of  the  congenitally  narrow  esophagus. 
It  is  not  uncommon  to  meet  with  cases  of  adults  who  have  ''never 
swallowed  as  well  as  other  people,"  and  in  whom  cicatricial  and 
spasmodic  stenosis  can  be  excluded  by  esophagoscopy,  which 
demonstrates  an  obvious  narrowing  of  the  esophageal  lumen. 
These  cases  are  doubtless  congenital. 

Webs  in  the  upper  third  of  the  esophagus  are  best  determined  by 
the  passage  of  a  large  esophagoscope  which  puts  the  esophagus  on 
the  stretch.  The  webs  may  be  broken  by  the  insertion  of  a  closed 
alligator  forceps,  which  is  then  withdrawn  with  opened  blades. 
Better  still  is  the  dilator  shown  in  Fig.  26.  This  retrograde  dilata- 
tion is  relatively  safe.  A  silk- woven  esophagoscopic  bougie  or 
the  metallic  tracheal  bougie  may  be  used,  with  proper  caution. 
Subsequent  dilatation  for  a  few  times  will  be  required  to  prevent 
a  reproduction  of  the  stenosis. 

Treatment  of  Esophageal  Anomalies. — Gastrostomy  is  required 
in  the  imperforate  cases.  Esophagoscopic  bouginage  is  very 
successful  in  the  cure  of  all  cases  of  congenital  stenosis.  Any  sort 
of  lumen  can  be  enlarged  so  any  well  masticated  food  can  be 
swallowed.  Careful  esophagoscopic  work  with  the  bougies  (Fig. 
40)  will  ultimately  cure  with  little  or  no  risk  of  mortality.  Any 
form  of  rapid  dilatation  is  dangerous.  Congenital  stenosis,  if  not 
an  absolute  atresia,  yields  more  readily  to  esophagoscopic  bougin- 
age than  cicatricial  stenosis. 

RUPTURE  AND  TRAUMA  OF  THE  ESOPHAGUS 

These  may  be  spontaneous  or  may  ensue  from  the  passage  of  an 
instrument,  or  foreign  body,  or  of  both  combined,  as  exemplified 
in  the  blind  attempts  to  remove  a  foreign  body  or  to  push  it 
downwards.  Digestion  of  the  esophagus  and  perforation  may 
result  from  the  stagnation  of  regurgitated  gastric  juice  therein. 


DISEASES    OF    THE    ESOPHAGUS  239 

This  condition  sometimes  occurs  in  profound  toxic  and  debilitated 
states.  Rupture  of  the  thoracic  esophagus  produces  profound 
shock,  fever,  mediastinal  emphysema,  and  rapid  sinking.  Pneu- 
mothorax and  empyema  follow  perforation  into  the  pleural  cavity. 
Rupture  of  the  cervical  esophagus  is  usually  followed  by  cervical 
emphysema  and  cervical  abscess,  both  of  which  often  burrow  into 
the  mediastinum  along  the  fascial  layers  of  the  neck.  Lesser 
degrees  of  trauma  produce  esophagitis  usually  accompanied  by 
fever  and  painful  and  difficult  swallowing. 

The  treatment  of  traumatic  esophagitis  consists  in  rest  in 
bed,  sterile  liquid  food,  and  the  administration  of  bismuth  subni- 
trate  (about  one  gramme  in  an  adult),  dry  on  the  tongue  every  4 
hours.  Rupture  of  the  esophagus  requires  immediate  gastrostomy 
to  put  the  esophagus  at  rest  and  supply  necessary  alimentation. 
Thoracotomy  for  drainage  is  required  when  the  pleural  cavity  has 
been  involved,  not  only  for  pleural  secretions,  but  for  the  constant 
and  copious  esophageal  leakage.  It  is  not  ordinarily  realized  how 
much  normal  salivary  drainage  passes  down  the  esophagus. 
The  customary  treatment  of  shock  is  to  be  applied.  No  attempt 
should  be  made  to  remove  a  foreign  body  until  the  traumatic 
lesions  have  healed.  This  may  require  a  number  of  weeks.  Decis- 
ion as  to  when  to  remove  the  intruder  is  determined  by  esophago- 
scopic  inspection. 

Subcutaneous  emphysema  does  not  require  puncture  unless 
gaseous,  or  unless  pus  forms.  In  the  latter  event  free  external 
drainage  becomes  imperative. 

ACUTE  ESOPHAGITIS 

This  is  usually  of  traumatic  or  cauterant  origin.  If  severe  or 
extensive,  all  the  symptoms  described  under  "Rupture  of  the 
Esophagus"  may  be  present.  The  endoscopic  appearances  are 
unmistakable  to  anyone  familiar  with  the  appearance  of  mucosal 


240  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

inflammations.  The  pale,  bluish  pink  color  of  the  normal  mucosa 
is  replaced  by  a  deep-red  velvety  swollen  appearance  in  which 
individual  vessels  are  invisible.  After  exudation  of  serum  into 
the  tissues,  the  color  may  be  paler  and  in  some  instances  a  typical 
edema  may  be  seen.  This  may  diminish  the  lumen  temporarily. 
Folds  of  swollen  mucosa  crowd  into  the  lumen  if  the  inflammation 
is  intense.  These  folds  are  sometimes  demonstrable  in  the 
roentgenogram  by  the  bismuth  or  barium  in  the  creases  between 
which  the  prominence  of  the  folds  show  as  islands  as  beautifully 
demonstrated  by  David  R.  Bowen  in  one  of  the  author's  cases. 
If  the  inflammation  is  due  to  corrosives,  a  grayish  exudate  may  be 
visible  early,  sloughs  later. 

ULCERATION  OF  THE  ESOPHAGUS 

Superficial  erosions  of  the  esophagus  are  by  no  means  an 
uncommon  accompaniment  of  the  stagnation  of  food  and  secretions. 
From  the  irritation  they  produce,  spastic  stenosis  may  occur, 
thus  constituting  a  vicious  circle;  the  spasm  of  the  esophagus 
increases  the  stagnation  which  in  turn  results  in  further  inflam- 
mation and  ultimate  ulceration.  Healing  of  such  ulcers  may 
result  in  cicatricial  contraction  and  organic  stenosis.  Ulceration 
may  follow  trauma  by  instrument,  foreign  body,  or  corrosive. 

DIFFERENTIAL  DIAGNOSIS  OF  ULCER  OF  THE  ESOPHAGUS 

Simple  ulcer  requires  the  exclusion  of  lues,  tuberculosis, 
epithelioma,  endothelioma,  sarcoma,  and  actinomycosis.  Simple 
ulcer  of  the  esophagus  is  usually  associated  with  stenosis,  spastic 
or  organic. 

Luetic  ulcers  commonly  show  a  surrounding  inflammatory 
areola,  and  they  usually  have  thickened  elevated  edges,  generally 
free  from  granulation  tissue,  with  a  pasty  center  not  bleeding 


DISEASES    OF    THE    ESOPHAGUS  241 

readily  when  sponged.  The  Wassermann  reaction  may  contribute 
to  the  diganosis;  but  if  negative,  a  thorough  and  prolonged  test 
with  mercury  is  imperative.  It  must  be  remembered  that  a 
person  with  lues  may  have  a  simple,  mixed,  or  malignant  ulcera- 
tion of  the  esophagus,  or  the  three  lesions  may  even  be  combined. 
It  may  be  in  some  cases  possible  to  demonstrate  the  treponema 
pallidum  in  scrapings  taken  from  the  ulcer. 

The  single  tuberculous  ulcer  is  usually  pale,  superficial,  and 
granular  in  base.  If  it  is  a  continuation  from  more  extensive  extra- 
esophageal  tuberculous  ulceration,  pale  cauliflower  granulations 
may  be  present.  Slight  cicatrices  may  be  seen.  Tuberculosis 
in  other  organs  can  almost  always  be  demonstrated  by  roent- 
genographic,  physical,  or  laboratory  studies.  Tuberculin  tests 
and  animal  injection  with  an  emulsion  of  a  specimen  of  tissue  may 
be  required.  The  specimen  must  be  taken  very  superficially  to 
avoid  risk  of  perforation. 

Sarcomatous  ulcers  do  not  differ  materially  in  appearance  from 
those  of  carcinoma,  but  they  are  much  more  rare. 

Carcinomatous  ulcer  is  usually  characterized  by  the  very 
vascular  bright  red  zone,  raised  edges,  fungations,  granulation 
tissue  that  bleeds  freely  on  the  lightest  touch,  and  above  all,  it  is 
almost  invariably  situated  on  an  infiltrated  base  which  communi- 
cates a  feeling  of  hardness  to  the  pressure  of  sponges  or  the  esopha- 
goscope  itself.  A  scar  may  be  from  the  healing  of  an  ulcer  from 
stasis,  or  one  of  specific  or  precancerous  character.  It  may  be  a 
cancerous  process  developing  on  the  site  of  a  scar,  so  that  the  pres- 
ence of  scar  tissue  does  not  absolutely  negative  malignancy.  As  a 
rule,  however,  scars  are  absent  in  cancer  of  the  esophagus.  The 
firm  and  sometimes  prominent  ridge  of  the  crossing  of  the  left 
bronchus  must  not  be  mistaken  for  infiltration,  and  the  esophago- 
scopist  must  be  familiar  with  the  normal  rigidity  of  the 
cricopharyngeus . 

16 


242  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

Mixed  infection  gives  to  all  esophageal  ulceration  a  certain 
uniformity  of  appearance,  so  that  laboratory  studies  of  smears  or 
histologic  and  bacteriologic  study  of  tissue  specimens  taken  from 
fungations  or  thickened  edges  are  often  required  to  confirm  the  en- 
doscopic diagnosis.  If  the  edges  are  thin  and  flat,  the  taking  of  a 
specimen  involves  some  risk;  fungations  can  be  removed  without 
risk;  so  can  nodules,  but  care  must  be  taken  that  projecting  folds 
are  not  mistaken  for  nodules.  It  is  always  wise  to  push  the  thera- 
peutic test  with  potassium  iodid  and  especially  mercury  in  any 
case  of  esophageal  ulceration  unassociated  with  stasis. 

Treatment  of  Acute  and  Subacute  Inflammation  and  Ulceration 
of  the  Esophagus. — Bismuth  subnitrate  in  doses  of  about  one 
gramme,  given  dry  on  the  tongue  and  swallowed  without  water, 
has  a  local  antiseptic  and  protective  action.  Its  antiseptic  power 
may  be  enhanced  by  the  addition  of  calomel  to  the  powder,  in 
such  amount  as  may  be  tolerated  by  the  bowels.  If  pain  be 
present  the  combination  of  a  grain  or  two  of  anesthesin  or  ortho- 
form  with  the  bismuth  will  be  grateful.  The  local  application  of 
argyrol  in  25  per  cent  watery  solution  is  also  of  great  value.  The 
mouth  and  teeth  are  to  be  kept  clean  with  a  mouth  wash  of  Dakin's 
solution,  I  part,  to  peppermint  water,  6  parts.  The  esophagus 
must  be  placed  at  rest  as  far  as  possible  by  liquid  diet  or,  if  need 
be,  by  gastrostomy. 

CHRONIC  ESOPHAGITIS 

This  is  usually  a  result  of  stagnation  of  food  or  secretion,  and 
will  be  considered  under  spasmodic  stenosis  and  diffuse  dilatation 
of  the  esophagus. 

A  very  marked  case  with  local  distress  and  pain  extending 
through  to  the  back  was  seen  by  the  author  in  consultation^^with 
Dr.  John  B.  Wright  who  had  made  the  diagnosis.  The  patient 
was  a  sufferer  from  ankylostomiasis. 


DISEASES    OF    THE    ESOPHAGUS  243 

COMPRESSION  STENOSIS  OF  THE  ESOPHAGUS 

The  esophagus  may  be  narrowed  by  the  pressure  of  any  peri- 
esophageal disease  or  anomaly.  The  lesions  most  frequently 
found  are: 

1.  Goiter,  cervical  or  thoracic. 

2.  Malignancy  of  any  of  the  intrathoracic  viscera. 

3.  Aneurysm. 

4.  Cardiac  and  aortic  enlargement. 

5.  Lymphadenopathies.     Hodgkins'  disease. 

Leukemia. 

Lues. 

Tuberculosis. 

Simple  infective  adenitis. 

6.  Lordosis. 

7.  Enlargement  of  the  left  hepatic  lobe. 

Endoscopically,  compression  stenosis  of  the  esophagus  is 
manifested  by  a  slit-like  crevice  which  occupies  the  place  of  the 
lumen  and  which  does  not  open  up  readily  before  the  advancing 
tube.  The  long  axis  of  the  slit  is  almost  always  at  right  angles  to 
the  compressive  mass,  if  the  esophageal  wall  be  uninvolved.  The 
covering  mucosa  may  be  normal  or  it  may  show  signs  of  chronic 
inflammation.  Malignant  compressions  are  characterized  by 
their  hardness  when  palpated  with  the  tube.  Associated  pressure 
on  the  recurrent  laryngeal  nerve  often  makes  laryngeal  paralysis 
coexistent.  The  nature  of  the  compressive  mass  will  require  for 
its  determination  the  aid  of  the  roentgenologist,  internist,  and 
clinical  laboratory.  Compression  by  the  enlarged  left  auricle 
has  been  observed  a  number  of  times.  The  presence  of  aneurysm 
is  a  distinct  contraindication  to  esophagoscopy  for  diagnosis  except 
in  case  of  suspected  foreign  body. 

Treatment  of  compressive  stenosis  of  the  esophagus  depends  upon 
the  nature  of  the  compressive  lesion  and  is  without  the  realm  of 
endoscopy.  In  uncertain  cases  potassium  iodid,  and  especially 
mercury,  should  always  be  given  a  thorough  and  prolonged  trial; 


244  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

an  occasional  cure  will  result.     Esophageal  intubation  is  indicated 
in  all  conditions  except  aneurysm.     Gastrostomy  should  be  done 

early  when  necessary. 

DIFFUSE  DILATATION  OF  THE  ESOPHAGUS 

This  is  practically  always  due  to  stagnation  ectasia,  which  is 
invariably  associated  with  either  organic  or  "spasmodic"  stricture, 
existing  at  the  time  of  observation  or  at  some  time  prior  thereto. 
The  dilating  effect  of  the  repeatedly  accumulated  food  results  in  a 
permanent  enlargement,  so  that  the  esophagus  acts  as  the  reser- 
voir of  a  large  funnel  with  a  very  small  opening.  When  food  is 
swallowed  the  esophagus  fills,  and  the  contents  trickle  slowly 
through  the  opening.  Gases  due  to  fermentation  increase  the 
distension  and  cause  substernal  pressure,  discomfort,  and  belching, 
A  very  large  dilatation  of  the  thoracic  esophagus  indicates  spastic 
stenosis.  Cicatricial  stenoses  do  not  result  in  such  large  dilata- 
tions and  the  dilatation  above  a  malignant  stenosis  is  usually 
slight,  probably  because  of  its  relatively  shorter  duration. 

The  treatment  of  diffuse  esophageal  dilatation  consists  in  dilating 
the  "diaphragmatic  pinchcock"  that  is,  the  hiatal  esophagus. 
Chronic  esophagitis  is  to  be  controlled  by  esophageal  lavage,  the 
regulation  of  the  diet  to  liquefiable  foods  and  the  administration 
of  bismuth  subnitrate.  The  patient  can  be  taught  to  do  the 
lavage.  The  local  esophagoscopic  application  of  a  small  quantity 
of  a  25  per  cent  watery  solution  of  argyrol  may  be  required  for 
the  static  esophagitis.  The  redundancy  probably  never  disap- 
pears; but  functional  and  subjective  cures  are  usually  obtainable. 


CHAPTER  XXXI 

DISEASES  OF  THE  ESOPHAGUS   {Continued) 

SPASMODIC  STENOSIS  OF  THE  ESOPHAGUS 

Etiology. — The  functional  activity  of  the  esophagus  is  depend- 
ent upon  reflex  action.  The  food  is  propulsed  in  a  peristaltic 
wave  by  the  same  mechanism  as,  and  through  an  innervation 
(Auerbach  and  Meissner  plexus)  similar  to  that  which  controls 
intestinal  movements.  The  vagus  also  is  directly  concerned 
with  the  deglutitory  act,  for  swallowing  is  impossible  if  both  vagi 
are  cut.  Anything  which  unduly  disturbs  this  reflex  arc  may 
serve  as  an  exciting  cause  of  spasmodic  stenosis.  Bolting  of  food, 
superficial  erosions,  local  esophageal  disease,  or  a  small  foreign 
body,  may  produce  spasmodic  stenosis.  Spasm  secondary  to 
disease  of  the  stomach,  liver,  gall  bladder,  appendix,  or  other 
abdominal  organ  is  clinically  well  recognize/i.  A  perpetuating 
cause  in  established  cases  is  undoubtedly  "nerve  cell  habit," 
and  in  many  cases  there  is  an  underlying  neurotic  factor.  Shock 
as  an  exciting  cause  has  been  well  exemplified  by  the  number 
of  cases  of  phrenospasm  developing  in  soldiers  during  the  World 
War. 

Crico pharyngeal  spasmodic  stenosis  usually  presents  the  sub- 
jective symptom  of  difliculty  in  starting  the  bolus  of  food  down- 
ward. Once  started,  the  food  passes  into  the  stomach  unimpeded. 
Regurgitation,  if  it  occurs,  is  immediate.  The  condition  consists 
in  a  tonic  contraction,  ahead  of  the  bolus,  of  the  circular  fibers  of 
the  inferior  constrictor  known  as  the  cricopharyngeus  muscle,  or 
in  a  failure  of  this  muscle  to  relax  so  as  to  allow  the  bolus  to  pass. 

245 


246  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

In  either  case  the  disorder  may  be  secondary  to  an  organic  lesion. 
Local  malignant  disease  or  foreign  bodies  may  be  the  cause. 
Globus  hystericus,  "lump  in  the  throat,"  and  the  sense  of  con- 
striction and  choking  during  emotion  are  due  to  the  same  spas- 
modic condition. 

Diagnosis. — At  esophagoscopy  there  will  be  found  marked 
exaggeration  of  the  usual  spasm  which  occurs  at  the  cricopharyn- 
geus  during  the  introduction  of  the  tube.  The  lumen  may  assume 
various  shapes,  or  be  so  tightly  closed  that  the  folds  form  a 
mammilliform  projection  in  the  center.  If  the  spasm  gradually 
yields,  and  a  full-sized  esophagoscope  passes  without  further 
resistance,  it  may  be  stated  that  the  esophagus  is  of  normal 
calibre,  and  a  diagnosis  of  spasmodic  stenosis  can  be  made.  Con- 
siderable experience  is  required  to  distinguish  between  normal 
and  pathologic  spasm  in  an  unanesthetized  individual.  To  the 
less  experienced  esophagoscopist,  examination  under  ether  anes- 
thesia is  recommended.  Deep  anesthesia  will  relax  the  normal 
cricopharyngeal  reflex  closure  as  well  as  any  abnormal  spasm, 
thus  assisting  in  the  differentiation  between  an  organic  stricture 
and  one  of  functional  character.  Under  deep  general  anesthesia, 
however,  it  is  impossible  to  differentiate  between  the  normal 
reflex  and  a  spasmodic  condition,  since  both  are  abolished.  Many 
cases  of  intermittent  esophageal  stenosis  supposed  to  be  spasmodic 
are  due  to  organic  narrowness  of  lumen  plus  lodgement  of  food, 
obstructive  in  itself  and  in  the  esophagitis  resulting  from  its 
presence.  The  organic  narrowing,  congenital  or  pathologic,  is 
readily  recognizable  esophagoscopically. 

Treatment. — The  fundamental  cause  of  the  disturbance  of  the 
reflex  should  be  searched  for,  and  treated  according  to  its  nature. 
Purely  functional  cases  are  often  cured  by  the  passage  of  a  large 
esophagoscope.     Recurrences    may    require    similar    treatment. 


DISEASES    OF    THE    ESOPHAGUS  247 

FUNCTIONAL  HIATAL  STENOSIS.     HIATAL  ESOPHAGISMUS. 

PHRENOSPASM,  DIAPHRAGMATIC  PINCHCOCK  STENOSIS. 

(SO-CALLED  CARDIOSPASM) 

There  is  no  sphincteric  muscular  arrangement  at  the  cardiac 
orifice  of  the  esophagus,  so  that  spasmodic  stenosis  at  this  level  is 
not  possible  and  the  term  cardiospasm  is,  therefore,  a  misnomer. 
It  was  first  demonstrated  by  the  author  that  in  so-called  cardio- 
spasm the  functional  closure  of  the  esophagus  occurred  at  the 
diaphragmatic  level,  and  that  it  was  due  to  the  ^^diaphragmatic 
pinchcock."  Anatomical  studies  have  corroborated  this  finding 
by  demonstrating  a  definite  sphincteric  mechanism  consisting  of 
muscle  bands  springing  from  the  crura  of  the  diaphragm  and 
surrounding  the  esophagus  at  the  under  surface  of  the  hiatus. 
An  inspection  of  the  cadaveric  diaphragm  from  below  will  demon- 
strate an  arrangement  like  double  shears  admirably  adapted  to 
this  "pinchcock"  action.  Further  confirmation  is  the  fact  that 
all  dilatation  of  the  esophagus  incident  to  spasm  at  its  lower 
extremity  is  situated  above  the  diaphragm.  In  passing  it  may  be 
stated  that  the  pinchcock  action,  plus  the  kinking  of  the  esophagus 
normally  prevents  regurgitation  when  a  man  with  a  full  stomach 
' '  stands  on  his  head  "  or  inverts  his  body.  For  the  upward  escape 
of  food  from  the  stomach  an  involuntary  co-ordinated  antiperis- 
taltic cycle  is  necessary.  The  dilatation  resulting  from  phreno- 
spasm  may  reach  great  size  (Fig.  96a),  and  the  capacity  of  the  sac 
may  be  as  much  as  two  liters.  While  the  esophagus  is  usually 
dilated,  the  stomach  on  the  other  hand  is  often  contracted,  largely 
from  lack  of  distention  by  food,  but  possibly  also  because  of  a 
spastic  state  due  to  the  same  causes  as  the  phrenospasm. 
Recently  Mosher  has  demonstrated  that  hepatic  abnormality  may 
furnish  an  organic  cause  in  many  cases  formerly  considered 
spasmodic. 

The  symptoms  of  hiatal  esophagismus  are  variable  in  degree. 


248  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

Substernal  distress,  with  a  feeling  of  fullness  and  pressure  followed 
by  eructations  of  gas  and  regurgitation  of  food  within  a  period  of 
a  quarter  of  an  hour  to  several  hours  after  eating,  are  present. 
If  the  esophageal  dilatation  be  great,  regurgitation  may  occur 
only  after  an  accumulation  of  several  days,  when  large  quantities 
of  stale  food  will  be  expelled.  The  general  nutrition  is  impaired, 
and  there  is  usually  the  history  of  weight  loss  to  a  certain  level  at 
which  it  is  maintained  with  but  slight  variation.  This  is  explained 
by  the  trickling  of  liquified  food  from  the  esophageal  reservoir 
into  the  stomach  as  the  spasm  intermittently  relaxes,  this  occur- 
ring usually  before  a  serious  state  of  inanition  supervenes.  At 
times  the  hiatal  spasms  are  extremely  violent  and  painful,  the  pain 
being  referred  from  the  xiphoid  region  to  the  back,  or  upward  into 
the  neck.  Patients  are  often  conscious  of  the  times  of  patulency 
of  the  esophagus;  they  will  know  the  esophagus  to  be  open  and 
will  eat  without  hesitation,  or  will  refuse  food  with  the  certain 
knowledge  that  it  will  not  pass  into  the  stomach.  Periods  of 
remission  of  symptoms  for  months  and  years  are  noted.  The 
neurotic  character  of  the  lesion  in  some  cases  is  evidenced  by  the 
occasionally  sudden  and  startling  cures  following  a  single  dilata- 
tion, as  well  as  by  the  tendency  to  relapse  when  the  individual  is 
subject  to  what  is  for  him  undue  nervous  tension.  In  a  very  few 
cases,  with  patients  of  rather  a  stolid  type,  all  neurotic  tendencies 
seem  to  be  absent. 

The  diagnosis  of  hiatal  esophagismus  requires  the  exclusion  of 
local  organic  esophageal  lesions.  In  the  typical  case  with  marked 
dilatation,  the  esophagoscopic  findings  are  diagnostic.  A  white, 
pasty,  macerated  mucosa,  and  normally  contracted  hiatus  esopha- 
geus  which  when  found  permits  the  large  esophagoscope  to  pass 
into  the  stomach,  will  be  recognized  as  characteristic  by  anyone 
who  has  seen  the  condition.  In  the  cases  with  but  little  esopha- 
geal distension  the  diagnosis  is  confirmed  by  the  constancy  of  the 


DISEASES    OF    THE    ESOPHAGUS  249 

obstruction  to  a  barium  mixture  at  the  phrenic  level,  while  at 
esophagoscopy  the  usual  resistance  at  the  hiatus  esophageus  is 
found  not  to  be  increased,  and  no  other  local  lesion  is  found  as 
the  esophagoscope  enters  the  stomach.  It  is  the  failure  of  the  dia- 
phragmatic pinchcock  to  open,  as  in  the  normal  deglutitory  cycle, 
rather  than  a  spasmodic  tightness,  that  obstructs  the  food.  The 
presence  of  organic  stenosis  at  the  hiatus  may  remove  the  case 
altogether  from  the  spasmodic  class,  or  a  cicatricial  or  infiltrated 
narrowing  may  be  the  result  of  static  esophagitis.  A  compressive 
stenosis  due  to  hepatic  abnormality  may  simulate  spasmodic 
stenosis  as  shown  by  Mosher,  who  believes  that  75  per  cent  of 
so-called  cardiospasms  are  organic. 

Treatment  of  hiatal  esophagismus  {so-called  cardiospasm) 
consists  in  the  over-dilatation  of  the  "diaphragmatic  pinchcock" 
or  hiatus  esophageus,  and  in  proper  remedial  measures  for  the 
removal  of  the  underlying  neurosis.  The  simple  passage  of  the 
esophagoscope  suffices  to  cure  some  cases.  Further  dilatation 
by  endoscopic  guidance  may  be  obtained  by  the  introduction  of 
Mosher's  divulsor  through  the  esophagoscope,  by  which  accurate 
placement  is  obtained.  The  distension  should  not  usually  exceed 
25  mm.  Numerous  water  and  air  bags  have  been  devised  for 
stretching  the  hiatus,  and  excellent  results  have  been  obtained 
by  their  use.  Possibly  some  of  the  cures  have  been  due  to  the 
dilatation  of  organic  lesions,  or  to  the  crowding  back  of  an  enlarged 
malposed,  or  otherwise  abnormal  left  lobe  of  the  liver,  which 
Mosher  has  shown  to  be  an  etiologic  factor. 

Certain  cases  prove  very  obstinate  of  cure,  and  require  eso- 
phageal lavage  for  the  esophagitis,  and  feedings  through  the  stom- 
ach tube  to  increase  nutrition  and  to  dilate  the  contracted 
stomach.  Gastrostomy  for  feeding  rarely  becomes  necessary,  for  a 
stomach  tube  can  always  be  placed  with  the  esophagoscope  if  it 
will  not  pass  otherwise.  Retrograde  dilatation  with  the  fingers 
through  a  gastrostomy  opening  has  been  done,  but  seems  hardly 


2::0 


BRONCHOSCOPY  AND  ESOPHAGOSCOPY 


through  a  gastrostomy  opening  has  been  done,  but  seems  hardly 
warranted  in  view  of  the  excellent  results  obtainable  from  above. 
Instructions  should  be  given  concerning  the  proper  mastication  of 
food,  and  during  treatment  the  frequent  partaking  of  small 
quantities  of  Hquid  foods  is  recommended.  Liquids  and  foods 
should  be  neither  hot  nor  cold.  The  neurologist  should  be 
consulted  in  cases  deemed  neurotic. 


Fig.   96a. — Functional  hiatal  stenosis.     Cramp  of  the  diaphragmatic  pinchcock 
(so-called  cardiospasm). 

Endocrine  imbalance  should  be  investigated  and  treated,  as 
urged  by  MacNab. 

Esophageal  antiperistalsis  is  the  name  given  by  the  author  to  a 
heretofore  undescribed  disease  associated  with  regurgitation  of 
food  from  the  esophagus,  the  food  not  having  reached  the  stomach. 
It  may  be  continuous  or  paroxysmal  and  may  be  of  so  serious  a 
degree  as  to  threaten  starvation.  The  best  treatment  in 
severe  cases  is  gastrostomy  to  put  the  esophagus  at  rest.  Milder 
cases  get  well  under  liquid  diet,  rest  in  bed,  endocrine  therapy, 
cure  of  associated  abdominal  disease,  etcetera. 


CHAPTER  XXXII 

DISEASES  OF  THE  ESOPHAGUS   {Continued) 

CICATRICIAL  STENOSIS  OF  THE  ESOPHAGUS 

Etiology. — The  accidental  swallowing  of  caustic  alkali  in 
solutions  of  lye  or  proprietary  washing  and  cleansing  powders, 
is  the  most  frequent  cause  of  cicatricial  stenosis.  Commercial 
lye  preparations  are  about  95  per  cent  sodium  hydroxide.  The 
cleansing  and  washing  powders  contain  from  eight  to  fifty  per  cent 
of  caustic  alkali,  usually  soda  ash,  and  are  sold  by  grocers  every- 
where. The  labels  on  their  containers  not  only  give  no  warning 
of  the  dangerous  nature  of  the  contents  nor  antidotal  advice, 
but  have  such  directly  misleading  statements  as  :  ''Will  not  injure 
the  most  delicate  fabric,"  "Will  not  injure  the  hands,"  etc. 
Utensils  used  to  measure  or  dissolve  the  powders  are  afterward 
used  for  drinking,  without  rinsing,  and  thus  the  residue  of  the 
pow^der  remaining  is  swallowed  in  strong  solution.  At  other 
times  solutions  of  lye  are  drunk  in  mistake  for  water,  cofifee,  or 
wine.  These  entirely  preventable  accidents  w^ould  be  rare  if 
they  were  as  conspicuously  labelled  "Poison"  as  is  required  by 
law  in  the  case  of  these  and  any  other  poisons,  when  sold  by 
druggists.  The  necessity  for  such  labelling  is  even  greater  with 
the  lye  preparations  because  they  go  into  the  kitchen,  whereas 
the  drugs  go  to  the  medicine  shelf,  out  of  the  reach  of  children. 
"Household  ammonia,"  "salts  of  tartar"  (potassium  carbonate), 
"washing  soda"  (sodium  carbonate),  mercuric  chloride,  and  strong 
acids  are  also,  though  less  frequently,  the  cause  of  cicatricial 
esophageal  stricture.  Tuberculosis,  lues,  scarlet  fever,  diphtheria, 
enteric  fever  and  pyogenic  conditions  may  produce  ulceration 


252 


BRONCHOSCOPY  AND  ESOPHAGOSCOPY 


followed  by  cicatrices  of  the  esophagus.  Spasmodic  stenosis 
with  its  consequent  esophagitis  and  erosions, 
and,  later,  secondary  pyogenic  infection,  may 
result  in  serious  cicatrices.  Peptic  ulcer  of 
the  lower  esophagus  may  be  a  cause.  The 
prolonged  sojourn  of  a  foreign  body  is  likely 
to  result  in  cicatricial  narrowing. 

Location  of  Cicatricial  Esophageal  Stric- 
tures.— The  strictures  are  often  multiple  and 
their  lumina  are  rarely  either  central  or 
concentric  (Fig.  97).  In  order  of  frequency 
the  sites  of  cicatricial  stenosis  are:  i.  At  the 
crossing  of  the  left  bronchus;  2.  In  the  region 
of  [the  'cricopharyngeus ;  3.  At  the  hiatal 
level.  Stricture  at  the  cardia  has  rarely 
been  encountered  in  the  Bronchoscopic  Clinic. 
Stenoiss  of  the  pylorus  has  been  noted,  but 
is  rare. 

Prognosis. — Spontaneous  recovery  from 
cicatricial  stenosis  probably  never  occurs, 
and  the  mortality  of  untreated  small  lumen 
strictures  is  very  high.  Blind  methods  of 
dilatation  are  almost  certain  to  result  in 
death  from  perforation  of  the  esophageal 
wall,  because  some  pressure  is  necessary  to 
dilate  a  stricture,  and  the  point  of  the 
bougie,  not  being  under  guidance  of  the 
eye,  is  certain  at  sometime  or  other  to  be 
engaged  in  a  pocket  instead  of  in  the  stric- 
ture. Pressure  then  results  in  perforation  of 
the  bottom  of  the  pocket  (Fig.  98).  This  accident  is  contributed 
to  by  dilatation  with  the  wrinkled,  scarred  floor  which  usually 


Fig.  97. — Schematic 
illustration  of  a  series 
of  eccentric  strictures 
with  i  n  t  erstrictural 
sacculations,  in  the 
esophagus  of  a  boy 
aged  four  years.  The 
strictures  were  divulsed 
seriatim  from  above 
downward  with  the 
divulsor,  the  esophageal 
wall,  D,  being  moved 
sidewise  to  the  position 
of  the  dotted  line  by 
means  of  a  small  esoph- 
agoscope  inserted 
through  the  upper  stric- 
ture, A,  after  divulsion 
of  the  latter. 


::  r>  ^  J  J  0  0 


DISEASES    OF    THE    ESOPHAGUS 


253 


develops  above  the  stricture.  Rapid  divulsion  and  internal 
esophagotomy  are  mechanically  very  easily  and  accurately  done 
through  the  esophagoscope,  and  would  yield  a  few  prompt  cures; 
but  the  mortahty  would  be  very  high.     Under  certain  circum- 


Rilse 

concejbtion 


Fig.  98. — Schema  illustrating  the  mechanism  of  perforation  by  blind  bouglnage. 
On  encountering  resilient  resistance  the  operator,  having  a  false  conception,  pushes 
on  the  bougie.  Perforation  results  because  in  reality  the  bougie  is  in  a  pocket  of 
the  suprastrictural  eccentric  dilatation. 


stances,  to  be  explained  below,  gentle  divulsion  of  the  proximal 
one  of  a  series  of  strictures  has  to  be  done.  With  proper  pre- 
cautions and  a  gentle  hand,  the  risk  is  slight.  Under  esophago- 
scopic  bouginage  the  prognosis  is  favorable  as  to  ultimate  cure, 
the  duration  of  the  treatment  varying  with  the  number  of  stric- 
tures, the  tightness,  and  the  extent  of  the  fibrous  tissue-changes 
in  the  esophageal  wall.     Mortality  from  the  endoscopic  procedure 


2  54  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

is  almost  nil,  and  if  gastrostomy  is  done  early  in  the  tightly 
stenosed  cases,  ultimate  cure  may  be  confidently  expected  with 
careful  though  prolonged  treatment. 

Symptoms. — Dysphagia,  regurgitation,  distress  after  eating, 
and  loss  of  weight,  vary  with  the  degree  of  the  stenosis.  The 
intermittency  of  the  symptoms  is  sometimes  confusing,  for  the 
lodgment  of  relatively  large  particles  of  food  often  simulates  a 
spasmodic  stenosis,  and  in  fact  there  is  often  an  element  of  spasm 
which  holds  the  foreign  body  in  the  strictured  area  until  it  relaxes. 
Static  esophagi tis  results  in  a  swelling  of  the  esophageal  walls  and 
a  narrowing  of  the  lumen,  so  that  swallowing  is  more  or  less 
troublesome  until  the  esophagitis  subsides. 

Esophagoscopic  Appearances  of  Cicatricial  Stenosis. — The 
color  of  the  cicatricial  area  is  usually  paler  than  the  normal 
mucosa.  The  scars  may  be  very  white  and  elevated,  or  they  may 
be  flush  with  the  normal  mucosa,  or  even  depressed.  Occasion- 
ally the  cicatrix  is  annular,  but  more  often  it  is  eccentric  and 
involves  only  a  part  of  the  circumference  of  the  wall.  If  the 
amount  of  scar  tissue  is  small,  the  lumen  maintains  its  mobility; 
opens  and  closes  during  respiration,  cough,  and  vomiturition. 
Between  two  strictures  there  is  often  a  pouch  containing  food 
remnants.  It  is  rarely  possible  to  see  the  lumen  of  the  second 
stricture,  because  it  is  usually  eccentric  to  the  first.  Stagnation 
of  food  results  in  superjacent  dilatation  and  esophagitis.  Erosions 
and  ulcerations  which  follow  the  stagnation  esophagitis  increase 
the  cicatricial  stenosis  in  their  healing. 

Differential  Diagnosis. — When  the  underlying  condition  is 
masked  by  inflammation  and  ulceration,  these  lesions  must  be 
removed  by  frequent  lavage,  the  administration  of  bismuth  sub- 
nitrate  with  the  occasional  addition  of  calomel  powder,  and  the 
limitation  of  the  diet  to  strained  liquids.  The  cicatricial  nature 
of  the  stenosis  can  then  be  studied  to  better  advantage.     In  most 


DISEASES    OF    THE    ESOPHAGUS  255 

cases  the  cicatrices  are  unmistakably  conspicuous.  Spasmodic 
stenoses  are  differentiated  by  the  absence  of  cicatrices  and  the 
yielding  of  the  stenosis  to  gentle  but  continuous  pressure  of  the 
esophagoscope.  While  it  is  possible  that  spasmodic  stenosis  may 
supplement  cicatricial  stenosis,  it  is  certainly  exceedingly  rare. 
Nearly  all  of  the  occasions  in  which  a  temporary  increase  of  the 
stenosis  in  a  cicatricial  case  is  attributed  to  an  element  of  spasm, 
the  real  cause  of  the  intermittency  is  not  spasm  but  obstruction 
caused  by  food.  This  occurs  in  three  ways:  i.  Actual  "corking" 
of  the  strictured  lumen  by  a  fragment  of  food,  in  which  case 
intermittency  may  be  due  to  partial  regurgitation  of  the  "cork- 
ing" mass  with  subsequent  sinking  tightly  into  the  stricture.  2. 
The  "cork"  may  dissolve  and  pass  on  through  to  be  later  replaced 
by  another.  3.  Reactionary  swelling  of  the  esophageal  mucosa 
due  to  stagnation.  Here  again  the  obstruction  may  be  prolonged, 
or  it  may  be  quite  intermittent,  due  to  a  valve-like  action  of  the 
swollen  mucosal  surfaces  or  folds  intermittently  coming  in  contact. 
Cancerous  stenosis  is  accompanied  by  infiltration  of  the  peri- 
esophageal tissue,  and  usually  by  projecting  bleeding  fungations. 
Cancer  may,  however,  develop  on  a  cicatrix,  favored  no  doubt  by 
chronic  inflammation  in  tissue  of  low  resistance.  Compression 
stenosis  of  the  esophagus  is  characterized  by  the  sudden  transition 
of  the  lumen  to  a  linear  or  crescentic  outline,  while  the  covering 
mucosa  is  normal  unless  esophagitis  be  present.  The  compressive 
mass  can  be  detected  by  the  sensation  transmitted  to  the  touch 
by  the  esophagoscope. 

Treatment. — Blind  bouginage  should  be  discarded  as  an  ob- 
solete and  very  dangerous  procedure.  If  the  stenosis  be  so  great 
as  to  interfere  with  the  ingestion  of  the  required  amount  of  liquids, 
gastrostomy  should  be  done  at  once  and  esophagoscopic  treatment 
postponed  until  water  hunger  has  been  relieved.  Gastrostomy 
aids  in  the  treatment  by  putting  the  esophagus  at  rest,  and  by 


256  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

affording  the  means  of  maintaining  a  high  degree  of  nutrition 
unhampered  by  the  variabihty  or  efhciency  of  the  swallowing 
function.  Careful  diet  and  gentle  treatment  will,  however, 
usually  avoid  gastrostomy.  The  diet  in  the  gastrostomy-fed 
patients  should  be  as  varied  as  in  oral  alimentation;  even  solids 
of  the  consistency  of  mashed  potatoes,  if  previously  forced  through 
a  wire  gauze  strainer,  may  be  forced  through  the  tube  with  a  glass 
injector.  Liquids  and  readily  liquefiable  foods  are  to  be  given  the 
non-gastrostomized  patient,  solids  being  added  when  demon- 
strated that  no  stagnation  above  the  stricture  occurs.  Thorough 
mastication  and  the  slow  partaking  of  small  quantities  at  a  time 
are  imperative.  Should  food  accumulation  occur,  the  esophagus 
should  be  emptied  by  regurgitation,  following  which  a  glassful 
of  warm  sodium  bicarbonate  solution  is  to  be  taken,  and  this  also 
regurgitated  if  it  does  not  go  through  promptly.  The  esophagus 
is  thus  lavaged  and  emptied.  In  all  these  cases,  whether  being 
fed  through  the  mouth  or  the  gastrostomic  tube,  it  is  very  impor- 
tant to  remember  that  milk  and  eggs  are  not  a  complete  dietary. 
A  pediatrist  should  be  consulted.  Prof.  Graham  has  saved  the 
lives  of  many  children  by  solving  the  nutritive  problems  in  the 
cases  at  the  Bronchoscopic  Clinic.  Fruit  and  vegetable  juices 
are  necessary.  Vegetable  soups  and  mashed  fruits  should  be 
strained  through  a  wire  gauze  coffee  strainer.  If  the  saliva  is 
spat  out  by  the  child  because  it  will  not  go  through  the  stricture 
the  child  should  be  taught  to  spit  the  saliva  into  the  funnel  of  the 
abdominal  tube.  This  method  of  improving  nutrition  was  dis- 
covered by  Miss  Groves  at  the  Bronchoscopic  Clinic. 

Esophagoscopic  houginage  with  the  author's  silk-woven  steel- 
shank  endoscopic  bougies  (Fig.  40)  has  proven  the  safest  and  most 
successful  method  of  treatment.  The  strictured  lumen  is  to  be 
centered  in  the  esophagoscopic  field,  and  three  successively  in- 
creasing sizes  of  bougies  are  used  under  direct  vision.     Larger  and 


DISEASES    OF    THE    ESOPHAGUS  257 

larger  bougies  are  used  at  the  successive  treatments  which  _are 
given  at  intervals  of  from  four  to  seven  days.  No  anesthesia, 
general  or  local,  is  used  for  esophagoscopic  bouginage.  The 
tightness  of  the  grasping  of  the  bougie  by  the  stricture  on  with- 
drawal, determines  the  limitation  of  sizes  to  be  used.  When  the 
upper  stricture  is  dilated,  lower  ones  in  the  series  are  taken  seria- 
tim. If  concentric,  two  or  more  closely  situated  strictures  may 
be  simultaneously  dilated.  For  the  use  of  bougies  of  the  larger 
sizes,  the  special  esophagoscopes  with  both  the  light-carrier  canal 
and  the  drainage  canal  outside  the  lumen  of  the  tube  are  needed. 
Functional  cure  is  obtained  with  a  relatively  small  lumen  at  the 
point  of  stenosis.  A  lumen  of  7  mm.  will  allow  the  passage  of  any 
well  masticated  food.  It  is  unwise  and  unsafe  to  attempt  to 
restore  the  lumen  to  its  normal  anatomic  size.  In  cicatricial 
stricture  cases  it  is  advisable  to  examine  the  esophagus  at  monthly 
periods  for  a  time  after  a  functional  cure  has  been  obtained,  in 
order  that  tendency  to  recurrence  may  be  early  detected. 

Dividsion  of  an  upper  stricture  may  be  deemed  advisable  in 
order  to  reach  others  lower  down,  especially  in  cases  of  multiple 
eccentric  strictures  (Fig.  97).  This  procedure  is  best  done  with 
the  author's  esophagoscopic  divulser,  accurately  placed  by  means 
of  the  esophagoscope;  but  divulsion  requires  the  utmost  care,  and 
a  gentle  hand.  Even  then  it  is  not  so  safe  as  esophagoscopic 
bouginage. 

Internal  esophagolomy  by  the  string-cutting  instruments  and 
esophagotome  are  relatively  dangerous  methods,  and  perhaps 
yield  in  the  end  no  quicker  results  than  the  slower  and  safe  bougin- 
age per  tubam. 

Electrolysis  has  been  used  with  varying  results  in  the  treatment 
of  cicatricial  stenosis. 

Thermic  bouginage  with  electrically  heated  bougies  has  been 
found  useful  in  some  cases  by  Dean  and  Imperatori. 

17 


258  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

String-swallowing,  with  the  passage  of  olives  threaded  over 
the  string  has  yielded  good  results  in  the  hands  of  some  operators. 
The  string  may  be  used  to  pull  up  dilators  in  increasing  sizes, 
introduced  through  a  gastrostomic  fistula.  The  string  stretched 
across  the  stomach  from  the  cardia  to  the  pylorus,  is  fished  out 
with  the  author's  pillar  retractor,  or  is  found  with  the  retrograde 
esophagoscope  (Fig.  43).  The  string  is  attached  to  a  dilator 
(Fig.  35),  and  a  fresh  string  is  pulled  in  to  replace  the  one  pulled 
out.  This  is  the  safest  of  the  blind  methods.  It  is  rarely  possible 
to  get  a  child  under  two  years  of  age  to  swallow  and  tolerate  a 
string.  It  is  better  after  each  treatment  to  draw  the  upper  end  of 
the  string  through  the  nose,  as  it  is  not  so  likely  to  be  chewed  off 
and  is  less  annoying.  With  the  esophagoscope,  the  string  is  not 
necessary,  because  the  lumen  of  the  stricture  can  be  exposed  to 
view  by  the  esophagoscope. 

Retrograde  esophagoscopy  through  a  gastrostomy  wound  offers 
some  advantages  over  peroral  treatment;  but  unless  the  gas- 
trostomy is  high,  the  procedure  is  undoubtedly  more  difficult. 
The  approach  to  the  lowest  stricture  from  below  is  usually  funnel 
shaped  and  free  from  dilatation  and  redundancy.  It  must  be 
remembered  the  stricture  seen  from  below  may  not  be  the  same 
one  seen  from  above.  Roentgenray  examination  with  barium 
mixture  or  esophagoscopes  simultaneously  in  situ  above  and  below 
are  useful  in  the  study  of  such  cases. 

Impermeable  strictures  of  the  cervical  esophagus  are  amenable 
to  external  esophagotomy,  with  plastic  reformation  of  the  esopha- 
gus. Those  in  the  middle  third  have  not  been  successfully  treated 
by  surgical  methods,  though  various  ingenious  operations  for  the 
formation  of  an  extrathoracic  esophagus  have  been  suggested  as 
means  of  securing  relief.  Impermeable  strictures  of  the  lower 
third  can  with  reasonable  safety  be  treated  by  the  Brenneman 
method,  which  consists  in  passing  the  esophagoscope  down  to  the 
stricture  while  the  surgeon,  inserting  his  finger  up  into  the  esopha- 


DISEASES    OF    THE    ESOPHAGUS  259 

gus  from  the  stomach,  can  feel  the  end  of  the  esophagoscope. 
An  incision  through  the  tissue  barrier  is  then  made  from 
below,  passing  the  knife  along  the  finger  as  a  guide.  A  soft  rubber 
stomach-tube  is  pulled  up  from  below  and  left  in  situ,  being 
replaced  at  intervals  by  a  fresh  one,  pulled  up  from  the  stomach, 
until  epithelialization  of  the  new  lumen  is  complete.  Catheters 
are  used  in  children.  In  replacing  the  catheter  or  stomach  tube 
the  fresh  one  is  attached  to  the  old  one  by  stitching  in  a  loop  of 
braided  silk.  Frequent  esophagoscopic  bouginage  will  be  required 
to  maintain  the  more  or  less  fistulous  lumen  until  it  is  epithelial- 
ized,  and  in  occasional  cases,  for  a  long  time  thereafter. 

In  cases  of  absolute  atresia  the  saliva  does  not  reach  the 
stomach.  No  one  realizes  the  quantity  of  normal  salivary  drain- 
age, nor  its  importance  in  nutritive  processes.  Oral  insalivation 
is  of  little  consequence  compared  to  esophagogastric  drainage. 
Gastrostomized  children  with  absolute  atresia  of  the  esophagus 
do  not  thrive  unless  they  regurgitate  the  salivary  accumulations 
into  the  funnel  of  the  gastrostomic  feeding  tube.  This  has  been 
abundantly  proven  by  observations  at  the  Bronchoscopic  Clinic. 
My  attention  was  first  called  to  this  clinical  fact  by  Mifs  Frances 
Groves  who  has  charge  of  these  cases. 

Intubation  of  the  esophagus  with  soft  rubber  tubes  has  occa- 
sionally proven  useful. 


CHAPTER  XXXIII 
DISEASES  OF  THE  ESOPHAGUS   (Continued) 
DIVERTICULUM  OF  THE  ESOPHAGUS 

Diverticula  may,   and  usually  do,  consist  in  a  pouching  by 
herniation,  of  the  whole  thickness  of  the  esophageal  wall;  or  they 


Fig.  99. — Traction  diverticulum  of  the  esophagus  rendered  visible  in  the  roent- 
genogram by  a  swallowed  opaque  mixture.  Case  of  H.  W.  Dachtler,  Am.  Journ. 
Roentgenology. 

may  be  herniations  of  the  mucosa  between  the  muscular  layers. 

They  are  classified  according  to  their  etiology,  as  traction  and 

pulsion  diverticula. 

Traction  diverticulum  of  the  esophagus   (Fig.    99)    is   a   rare 

260 


DISEASES    OF    THE    ESOPHAGUS 


261 


condition,  usually  occurring  in  the  thorax,  and  as  a  rule  con- 
stituting a  one-sided  enlargement  of  the  gullet  rather  than  a  true 
pouch  formation.  It  is  supposed  to  be 
formed  by  the  pulling  during  cough,  respi- 
ration,  and  swallowing,  on  localized 
adhesions  of  the  esophagus  to  periesopha- 
geal structures,  such  as  inflammatory 
peribronchial  glands. 

Diagnosis  is  often  incidental  to  exami- 
nation of  the  gastrointestinal  tract  for 
other  conditions,  because  traction  diver- 
ticula usually  cause  no  symptoms.  Unless 
a  very  large  esophagoscope  be  used,  a 
traction  diverticulum  may  easily  be  over- 
looked in  the  mucosal  folds.  Careful 
lateral  search,  however,  will  reveal  the 
dilatation,  and  the  localized  periesophageal 
fixation  may  be  demonstrated.  The  sub- 
diverticular  esophagus  is  readily  followed, 
its  lumen  opening  during  inspiration  unless 
very  close  to  the  diaphragm,  which  is  very 
rare.  Perhaps  most  cases  will  be  dis- 
covered by  the  roentgenologist.  It  has 
been  said  that  traction  diverticula  are 
more  readily  demonstrated  in  the  roent- 
genologic examination,  if  the  patient  be 
placed  with  pelvis  elevated. 

Pulsion  diverticulum  of  the  esophagus  is 
an  acquired  hernia  of  the  mucosa  between 
the  circular  and  oblique  fibers  of  the  inferior  constrictor  muscle 
of  the  pharynx.  A  congenital  anatomic  basic  factor  in  etiology 
probably  exists.     The  pouching  develops  in  the  middle  part  of 


Fig.  100. — Schema 
illustrative  of  the  etiology 
of  pressure  diverticula.  O, 
oblique  fibers  of  the  crico- 
pharyngeus  attached  to 
the  thyroid  cartilage,  T. 
The  fundiform  fibers,  F, 
encircle  the  mouth  of  the 
esophagus.  Between  the 
two  sets  of  fibers  is  a  gap 
in  the  support  of  the 
esophageal  wall,  through 
which  the  wall  herniates 
owing  to  the  pressure  of 
food  propelled  by  the 
oblique  fibers,  O,  advance 
of  the  bolus  being  resisted 
by  spasmodic  contraction 
of  the  orbicular  fibers,  F. 


262  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

the  posterior  wall,  between  the  orbicular  and  oblique  fibers 
of  the  cricopharyngeus  muscle,  at  which  point  there  is  a  gap, 
leaving  the  mucosa  supported  only  by  a  not  very  resistant  fascia 
(Fig.  I  go)  .  When  small,  the  sac  is  in  the  midline,  but  with  increase 
in  size,  it  presents  either  to  the  right  or  the  left  side,  commonly 
the  latter.  The  sac  may  be  very  small,  or  it  may  be  sufficiently 
large  to  hold  a  pint  or  more,  and  to  cause  the  neck  to  bulge  when 
filled.  When  large,  the  pouch  extends  into  the  mediastinum. 
It  will  be  seen  that  anatomically  the  pulsion  diverticulum  has  its 
origin  in  the  pharynx;  the  symptoms,  however,  are  referable  to 
the  esophagus  and  the  subdiverticular  esophagus  is  stenosed  by 
compression  of  the  pouch;  therefore,  it  is  properly  classified  as  an 
esophageal  disease. 

Etiology. — Pressure  diverticula  occur  after  middle  life,  and 
more  often  in  men  than  in  women.  The  hasty  swallowing  of 
unmasticated  food,  too  large  a  bolus,  defective  or  artificial  teeth, 
flaccidity  of  tissues,  and  spasm  of  the  cricopharyngeus  muscle, 
are  etiologic  factors.  Cicatricial  stenosis  below  the  level  of  the 
inferior  constrictor  is  a  contributory  cause  in  some  cases. 

Prognosis. — After  the  pouch  is  formed,  it  steadily  increases  in 
size,  since  the  swallowed  food  first  fills  and  distends  the  sac  before 
the  overflow  passes  down  the  esophagus.  When  a  pendulous 
sac  becomes  filled  with  food,  it  presses  on  the  subdiverticular 
esophagus,  and  produces  compression  stenosis;  so  that  there 
exists  a  "vicious  circle."  The  enlargement  of  the  sac  produces 
increasing  stenosis  with  consequent  further  distension  of  the 
pouch.  This  explains  the  clinically  observed  fact,  that  unless 
treated,  pulsion  diverticula  increase  progressively  in  size,  and 
consequently  in  distressing  symptoms.  The  sac  becomes  so 
large  in  some  cases  as  to  contribute  to  the  occurrence  of  cerebral 
apoplexy  by  interference  with  venous  return.  Practically  all 
cases  can  be  cured  by  radical  operation.     The  operative  mortality 


DISEASES    OF    THE    ESOPHAGUS  263 

varies  with  the  age,  state  of  nutrition,  and  general  health  of  the 
patient.  In  general  it  may  be  said  to  have  a  mortality  of  at  least 
10  per  cent,  largely  due  to  the  fact  that  most  cases  are  poor  surgical 
subjects.  Recurrences  after  radical  operation  are  due  to  a  per- 
sistence of  the  original  causes,  i.e.,  bolting  of  food;  stenosis,  spas- 
modic  or  organic,  of  the  esophageal  lumen;  and  weakness  in  the 
support  of  the  esophageal  wall,  which,  unsupported,  has  little 
strength  of  its  own. 

Symptoms. — Dysphagia,  regurgitation,  a  gurgling  sound  and 
subjective  bubbling  sensation  on  swallowing,  sour  odor  to  the 
breath,  and  cough,  are  the  chief  symptoms.  With  larger  pouches, 
emaciation,  pressure  sensation  in  the  neck  and  upper  mediastinum, 
and  the  presence  of  a  mass  in  the  neck  when  the  sac  is  filled,  are 
present.  Tracheal  compression  by  the  filled  pouch  may  produce 
dyspnea.  The  sac  may  be  emptied  by  pressure  on  the  neck,  this 
means  of  relief  being  often  discovered  by  the  patient.  The  sac 
sometimes  spontaneously  empties  itself  by  contraction  of  its 
enveloping  muscular  layer,  and  one  of  the  most  annoying  symp- 
toms is  the  paroxysm  of  coughing,  waking  the  patient,  when  during 
the  relaxation  of  sleep  the  sac  empties  itself  into  the  pharynx  and 
some  of  its  contents  are  aspirated  into  the  larynx.  There  are  no 
pathognomonic  symptoms.  Those  recited  are  common  to  other 
forms  of  esophageal  stenosis,  and  are  urgent  indications  for  diag- 
nostic esophagoscopy. 

Diagnosis. — Roentgenray  study  with  barium  mixtures,  is  the 
first  step  in  the  diagnosis  (Fig,  loi).  This  is  to  be  followed  by 
diagnostic  esophagoscopy.  Malignant,  spasmodic,  cicatricial, 
and  compression  stenosis  are  to  be  excluded  by  esophagoscopic 
appearances.  Aneurysm  is  to  be  eliminated  by  the  usual  means. 
The  Boyce  sign  is  almost  invariably  present,  and  is  diagnostic.  It 
is  elicited  by  telling  the  patient  to  swallow,  which  action  imprisons 
air  in  the  sac.     The  imprisoned  air  is  forced  out  hy  finger-pressure 


264 


BRONCHOSCOPY  AND  ESOPHAGOSCOPY 


on  the  neck,  over  the  sac.     The  exit  of  the  air  bubble  produces  a 
gurghng  sound  audible  at  the  open  mouth  of  the  patient. 

Esophagoscopic  Appearances  in  Pulsion  Diverticulum. — The 
esophagoscope  will  without  difficulty  enter  the  mouth  of  the  sac 
which  is  really  the  whole  bottom  of  the  pharynx,  and  will  be 
arrested  by  the  blind  end  of  the  pouch,  the  depth  of  which  may  be 


Fig.  loi.-^Pulsion  diverticulum  filled  with  bismuth  mixture  in  a  man  of  fifty  years. 

from  4  to  10  cm.  In  some  cases  the  bottom  of  the  pouch  is  in  the 
mediastinum.  The  walls  are  often  pasty,  and  may  be  eroded,  or 
ulcerated,  and  they  may  show  vessels  or  cicatrices.  On  withdraw- 
ing the  tube  and  searching  the  anterior  wall,  the  subdiverticular 
slit-like  opening  of  the  esophagus  will  be  found,  though  perhaps 
not  always  easily.  The  esophageal  speculum  will  be  found 
particularly  useful  in  exposing  the  subdiverticular  orifice,  and 
through  this  a  small  esophagoscope  may  be  passed  into  the  esopha- 


DISEASES    OF    THE    ESOPHAGUS  265 

gus,  thus  completing  the  diagnosis.  Care  must  be  exercised  not 
to  perforate  the  bottom  of  the  diverticular  pouch  by  pressure  with 
the  esophagoscope  or  esophageal  speculum.  The  walls  of  the 
sac  are  suprisingly  thin. 

Treatment  of  Pulsion  Diverticulum. — If  the  pouch  is  small,  the 
subdiverticular  esophageal  orifice  may  be  dilated  with  esophago- 
scopic  bougies,  thus  overcoming  the  etiologic  factor  of  spastic  or 
organic  stenosis.  The  redundancy  remains,  however,  though  the 
symptoms  may  be  relieved.  Cutting  the  common  wall  between 
the  esophagus  and  the  sac  by  means  of  scissors  passed  through  the 
endoscopic  tube,  has  been  successfully  done  by  Mosher. 

Various  methods  of  external  operation  have  been  devised, 
among  which  are:  (i)  Freeing  the  sac  through  an  external  cervical 
incision  and  suturing  its  fundus  upward  against  the  pharynx, 
which  has  proved  successful  in  some  cases.  (2)  Inversion  of  the 
sac  into  the  pharynx  and  suture  of  the  mouth  of  the  pouch.  In 
a  case  so  treated  the  pouch  was  blown  out  again  during  a  fit  of 
sneezing  eight  months  after  operation.  (3)  Plication  of  the  walls 
of  the  sac  by  catgut  sutures,  as  in  the  Matas  obliterative  operation 
for  aneurysm.  (4)  Freeing  and  removing  the  sac,  with  suture  of 
the  esophageal  wound.  (5)  Removal  of  the  sac  by  a  two-stage 
operation,  in  which  method  the  initial  step  is  the  deliverance  of  the 
sac  into  the  cervical  wound,  where  it  remains  surrounded  by  gauze 
packing  until  adhesions  have  walled  off  the  mediastinum.  The 
work  is  completed  by  cutting  off  the  sac  and  either  suturing  the 
esophageal  wound  or  touching  it  with  the  cautery,  and  allowing  it 
to  heal  by  granulation.  External  exposure  and  amputation  of  the 
sac  has  been  more  frequently  done  than  any  other  operation. 
Unless  the  pouch  is  large,  it  is  extremely  difficult  to  find  after  the 
surgeon  has  exposed  the  esophagus,  for  the  reasons  that  at  opera- 
tion it  is  empty  and  that  when  the  adhesions  about  it  are  removed 
the  walls  of  the  sac  contract.     After  removal,  the  sac  is  disappoint- 


266 


BRONCHOSCOPY  AND  ESOPHAGOSCOPY 


ingly  small  as  compared  with  its  previous  size  in  the  roentgeno- 
gram, which  shows  it  distended  with  opaque  material.  It  has  been 
the  chagrin  of  skilled  surgeons  to  find  the  diverticulum  present 


Fig.  I02. — Schematic  representation  of  esophagoscopic  aid  in  the  excision  of  a 
diverticulum  in  the  Gaub- Jackson  operation.  At  A  the  esophagoscope  is  repre- 
sented in  the  bottom  of  the  pouch  after  the  surgeon  has  cut  down  to  where  he  can 
feel  the  esophagoscope.  Then  the  esophagoscopist  causes  the  pouch  to  protrude 
as  shown  by  the  dotted  line  at  B.  After  the  surgeon  has  dissected  the  sac  entirely 
loose  from  its  surroundings,  traction  is  made  upon  the  sac  as  shown  at  H  and  the 
esophagoscope  is  inserted  down  the  lumen  of  the  esophagus  as  shown  at  C.  The 
esophagoscope  now  occupies  the  lumen  which  the  patient  will  need  for  swallowing. 
It  only  remains  for  the  surgeon  to  remove  the  redundancy,  without  risk  of  removing 
any  of  the  normal  wall.  The  esophagoscope  here  shown  is  of  the  form  squarely 
cut  oflF  at  the  end.  The  standard  form  of  instrument  with  slanted  end  will  serve  as 
well. 


functionally  and  roentgenographically  precisely  the  same  as 
before  the  performance  of  the  very  trying  and  difficult  operation. 
The  time  of  operation  may  be  shortened  at  least  by  one-half  by 
the  aid  of  the  esophagoscopist  in  the  Gaub-Jackson  operation. 
Intratracheally  insufflated  ether  is  the  anesthesia  of  choice.  After 
the  surgeon  has  exposed  the  esophagus  by  dissection,  the  endo- 


DISEASES    OF    THE    ESOPHAGUS  267 

scopist  introduces  the  esophagoscope  into  the  sac,  and  delivers  it 
into  the  wound,  while  the  surgeon  frees  it  from  adhesions.  The 
esophagoscope  is  now  withdrawn  from  the  pouch  and  entered  into 
the  esophagus  proper,  below  the  diverticulum,  while  the  surgeon 
cuts  off  the  hernial  sac  and  sutures  the  esophagopharyngeal  wound 
over  the  esophagoscope.  The  presence  of  the  esophagoscope 
prevents  too  tight  suture  and  possible  narrowing  of  the  lumen 
(Fig.  102). 

After-care. — Feeding  may  be  carried  on  by  the  placing  of  a 
small  nasal  feeding  tube  into  the  stomach  at  the  time  of  operation. 
Gastrostomy  for  feeding  as  a  preliminary  to  the  esophageal  opera- 
tion has  been  suggested,  and  is  certainly  ideal  from  the  viewpoint 
of  nutrition  and  esophageal  rest.  The  decision  of  its  performance 
may  perhaps  be  best  made  by  the  patient  himself.  Should  leak- 
age through  the  neck  occur,  the  fistula  should  be  flushed  by  the 
intake  of  sterile  water  by  mouth.  Oral  sepsis  should,  of  course, 
be  treated  before  operation  and  combated  after  operation  by 
frequent  brushing  of  the  teeth  and  rinsing  of  the  mouth  with 
Dakin's  solution,  one  part,  to  ten  parts  of  peppermint  water.  A 
postoperative  barium  roentgenogram  should  be  made  in  every  case 
as  a  matter  of  record  and  to  make  certain  the  proper  functioning 
of  the  esophagus. 


CHAPTER  XXXIV 

DISEASES  OF  THE  ESOPHAGUS  {Continued) 

PARALYSIS  OF  THE  ESOPHAGUS 

The  passage  of  liquids  and  solids  through  the  esophagus  is  a 
purely  muscular  act,  controlled,  after  the  propulsive  usually 
voluntary  start  given  to  the  bolus  by  the  inferior  constrictor,  by  a 
reflex  arc  having  connection  with  the  central  nervous  system 
through  the  vagus  nerve.  Gravity  plays  little  or  no  part  in  the 
act  of  deglutition,  and  alone  will  not  carry  food  or  drink  to  the 
stomach.  Paralysis  of  the  esophagus  may  be  said  to  be  motor  or 
sensory.  It  is  rarely  if  ever  unassociated  with  like  lesions  of 
contiguous  organs. 

Motor  paralysis  of  the  esophagus  is  first  manifested  by  inability 
to  swallow.  This  is  associated  with  the  accumulation  of  secretion 
in  the  pyriform  sinuses  (the  author's  sign  of  esophageal  stenosis) 
which  overflows  into  the  larynx  and  incites  violent  coughing. 
Motor  paralysis  may  affect  the  constrictors  or  the  esophageal 
muscular  fibers  or  both. 

Sensory  paralysis  of  the  esophagus  by  breaking  the  continuity 
of  the  reflex  arc,  may  so  impair  the  peristaltic  movements  as  to 
produce  aphagia.  The  same  filling  of  the  pyriform  sinuses  will  be 
noted,  but  as  the  larynx  is  usually  anesthetic  also,  it  may  be  that 
no  cough  is  produced  when  secretions  overflow  into  it. 

Etiology. — I.  Toxic  paralysis  as  in  diphtheria. 

2.  Functional  paralysis  as  in  hysteria. 

3.  Peripheral  paralysis  from  neuritis. 

4.  Central  paralysis,  usually  of  bulbar  origin. 

Embolism  or  thrombosis  of  the  posterior  cerebral  artery  is  a 

268 


DISEASES    OF    THE    ESOPHAGUS  269 

reported  cause  in  two  cases.  Lues  is  always  to  be  excluded  as 
the  fundamental  factor  in  the  groups  3  and  4.  Esophageal 
paralysis  is  not  uncommon  in  myasthenia  gravis. 

Esophagoscopic  findings  are  those  of  absence  of  the  normal 
resistance  at  the  cricopharyngeus,  flaccidity  and  lack  of  sensation 
of  the  esophageal  walls,  and  perhaps  adherence  of  particles  of 
food  to  the  folds.  The  hiatal  contraction  is  usually  that  normally 
encountered,  for  this  is  accomplished  by  the  diaphragmatic 
musculature.  In  paralysis  of  sensation,  the  reflexes  of  coughing, 
vomiturition  and  vomiting  are  obtunded. 

Diagnosis. — Hysteria  must  not  be  decided  upon  as  the  cause 
of  dysphagia,  until  after  esophagoscopy  has  eliminated  paralysis. 
Dysphagia  after  recent  diphtheria  should  suggest  paralysis  of  the 
esophagus.  The  larynx,  lips,  tongue,  and  pharynx  also,  are  usu- 
ally paralyzed  in  esophageal  paralysis  of  bulbar  origin.  The 
absence  of  the  cricopharyngeal  resistance  to  the  esophagoscope 
passed  without  anesthesia,  general  or  local,  is  diagnostic. 

Treatment. — The  internist  and  neurologist  should  govern  the 
basic  treatment.  Nutrition  can  be  maintained  by  feeding  with 
the  stomach-tube,  which  meets  no  resistance  to  its  passage. 
Should  this  be  contraindicated  by  ulceration  of  the  esophagus, 
gastrostomy  should  be  done. 

LUES  OF  THE  ESOPHAGUS 

Esophageal  syphilis  is  a  rather  rare  affection,  and  may  show 
itself  as  a  mucous  plaque,  a  gumma,  an  ulceration,  or  a  cicatrix. 
Cicatricial  stenosis  developing  late  in  life  without  history  of  the 
swallowing  of  escharotics  or  ulcerative  lesions  is  strongly  sugges- 
tive of  syphilis,  though  the  late  manifestation  of  a  congenital 
stenosis  is  a  possibility. 

Esophagoscopic  appearances  of  lues  are  not  always  character- 
istic.    As  in  any  ulcerative  lesion,  the  inflammatory  changes  of 


270  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

mixed  infections  mask  the  basic  nature.  The  mucous  plaque  has 
the  same  appearance  as  one  situated  on  the  velum,  and  gummata 
resemble  those  seen  in  the  mucosa  elsewhere.  There  is  nothing 
characteristic  in  luetic  cicatrices. 

The  diagnosis  of  luetic  lesions  of  the  esophagus,  therefore, 
depends  upon  the  history,  presence  of  luetic  lesions  elsewhere,  the 
serologic  reaction,  therapeutic  test,  examination  of  tissue,  and  the 
demonstration  of  the  treponema  pallidum.  The  therapeutic 
test  by  prolonged  saturation  of  the  system  with  mercury  is  impera- 
tive in  all  suspected  cases  and  no  other  negative  result  should  be 
deemed  sufficient. 

The  treatment  of  luetic  esophagitis  is  systemic,  not  local. 
Luetic  cicatrices  contract  strongly,  and  are  very  resistant  to 
treatment,  so  that  esophagoscopic  bouginage  should  be  begun  as 
early  as  possible  after  the  healing  of  a  luetic  ulceration,  in  order 
to  prevent  stenosis.  A  silk-woven  endoscopic  bougie  placed  in 
position  by  ocular  guidance,  and  left  in  situ  for  from  half  to  one 
hour  daily,  may  prevent  severe  contraction,  if  used  early  in  the 
stage  of  cicatrization.  Prolonged  treatment  is  required  for  the 
cure  of  established  luetic  cicatricial  stenosis.  If  gastrostomy  has 
been  done  retrograde  bouginage  (Fig.  35)  may  be  used. 
TUBERCULOSIS  OF  THE  ESOPHAGUS 

Esophageal  tuberculosis  is  not  commonly  met,  but  is  probably 
not  infrequently  associated  with  the  dysphagia  of  tuberculous 
laryngitis.  It  may  rarely  occur  as  a  primary  infection,  but  usually 
the  esophagus  is  involved  in  an  extension  from  a  tuberculous 
process  in  the  larynx,  mediastinal  lymphatics,  pleura,  bronchi,  or 
lungs. 

Primary  lesions  appear  as  superficial  erosions  or  ulcerations, 
with  a  surrounding  yellowish  granular  zone,  or  the  granules  may 
alone  be  present.  The  mucosa  in  tuberculous  lesions  is  usually 
pallid,  the  absence  of  vascularity  being  marked.     Invasion  from 


DISEASES    OF    THE    ESOPHAGUS  271 

the  periesophageal  organs  produces  more  or  less  localized  compres- 
sion and  fixation  of  the  esophagus.  The  character  of  open  ulcera- 
tion is  modified  by  the  mixed  infections.  Healed  tuberculous 
lesions,  sometimes  resulting  from  the  evacuation  of  tuberculous 
mediastinal  lymph  nodes  into  the  esophagus  may  be  encountered. 
The  local  fixation  and  cicatricial  contraction  may  be  the  site  of 
a  traction  diverticulum.  Tuberculous  esophago-bronchial  fistulae 
are  occasionally  seen. 

Diagnosis,  to  be  certain,  requires  the  demonstration  of  the 
tubercule  bacilli  and  the  characteristic  cell  accumulation  of  the 
tubercle  in  a  specimen  of  tissue  removed  from  the  lesion.  Acti- 
nomycosis must  be  excluded,  and  the  possibility  of  mixed  luetic 
and  tuberculous  lesions  is  to  be  kept  in  mind.  Post-tuberculous 
cicatrices  have  no  recognizable  characteristics. 

Treatment. — The  maintenance  of  nutrition  to  the  highest 
degree,  and  the  institution  of  a  strict  antituberculous  regime  are 
demanded.  Local  applications  are  of  no  avail.  Gastrostomy  for 
feeding  should  be  done  if  dysphagia  be  severe,  and  has  the  advan- 
tage of  putting  the  esophagus  at  rest.  The  passage  of  a  stomach- 
tube  for  feeding  purposes  may  be  done,  but  it  is  often  painful,  and 
is  dangerous  in  the  presence  of  ulceration.  Pain  is  not  marked 
if  the  lesion  be  limited  to  the  esophagus,  though  if  it  is  present 
orthoform,  anesthesin,  or  apothesin,  in  powder  form,  swallowed 
dry,  may  prove  helpful. 

VARIX  AND  ANGIOMA  OF  THE  ESOPHAGUS 

These  lesions  are  sometimes  the  cause  of  esophageal  hemor- 
rhage, the  regurgitated  blood  being  bright  red,  and  alkaline  in 
reaction,  in  contradistinction  to  the  acid  "coffee  ground"  blood 
of  gastric  origin.  Esophageal  varices  may  coexist  with  the 
common  dilatation  of  the  venous  system  in  which  the  veins  of  the 
rectum,    scrotum,    and    legs    are    most    conspicuously    affected. 


272  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

Cirrhosis  and  cancer  of  the  liver  may,  by  interference  with  the 
portal  circulation,  produce  dilatation  of  the  veins  in  the  lower 
third  of  the  esophagus.  Angioma  of  the  esophagus  is  amenable 
to  radium  treatment. 

ACTINOMYCOSIS  OF  THE  ESOPHAGUS 

Esophageal  actinomycosis  has  been  autoptically  discovered. 
Its  diagnosis,  and  differentiation  from  tuberculosis,  would  prob- 
ably rest  upon  the  microscopic  study  of  tissue  removed  esophago- 
scopically,  though  as  yet  no  such  case  has  been  reported. 

ANGIONEUROTIC  EDEMA 

Angioneurotic  edema  involving  the  esophagus,  may  produce 
intermittent  and  transient  dysphagia.  The  lesions  are  rarely 
limited  to  the  esophagus  alone;  they  may  occur  in  any  portion  of 
the  gastrointestinal,  genitourinary,  or  respiratory  tracts,  and 
concomitant  cutaneous  manifestations  usually  render  the  diagno- 
sis clear.     The  treatment  is  general. 

DEVIATION  OF  THE  ESOPHAGUS 

Deviation  of  the  esophagus  may  be  marked  in  the  presence  of  a 
deformed  vertebral  column,  though  dysphagia  is  a  very  uncommon 
symptom.  The  lack  of  esophageal  symptoms  in  deviation  of 
spinal  production  is  probably  explained  by  the  longitudinal  short- 
ening of  the  spine  which  accompanies  the  deflection.  Compres- 
sion stenosis  of  the  esophagus  is  commonly  associated  with 
deviations  produced  by  a  thoracic  mass. 


PLATE  IV 


A,  Gastroscopic  view  of  a  gastrojejunostomy  opening  drawn  patulous  by  the  tube 
mouth.  (Gastrojejunostomy  done  by  Dr.  George  L.  Hays.)  B,  Carcinoma  of  the 
lesser  curvature.  (Patient  afterward  surgically  explored  and  diagnosis  verified  by 
Dr.  John  J.  Buchanan.)  C,  Healed  perforated  ulcer.  (Patient  referred  by  Dr.  John 
W.  Boyce.) 


®® 


Drawn  from  a  case  of  postdiphtheric  subglottic  stenosis  cured  by  the  author's 
method  of  direct  galvanocauterization  of  the  hypertrophies.  A,  Immediately  after 
removal  of  the  intubation  tube;  hypertrophies  like  turbinals  are  seen  projecting  into 
the  subglottic  lumen.  B,  Five  minutes  later;  the  masses  have  now  closed  the  lumen 
almost  com[)letely.  The  patient  became  so  cyanotic  that  a  bronchoscope  was  at  once 
introduced  to  prevent  asphyxia.  C,  The  left  mass  has  been  cauterized  by  a  vertical 
application  of  the  incandescent  knife.  D,  Completely  and  permanently  cured  after 
repeated  cauterizations.      Direct  view;  recumbent  patient. 

Photoprocess  Reproductions  of  the  Author's  Oil-color  Drawings  from  Life 


CHAPTER  XXXV 
GASTROSCOPY 

The  stomach  of  any  individual  having  a  normal  esophagus 
and  normal  spine  can  be  explored  with  an  open-tube  gastroscope. 
The  adult  size  esophagoscope  being  53  cm.  long  will  reach  the 
stomach  of  the  average  individual.  Longer  gastroscopes  are  used, 
when  necessary,  to  explore  a  ptosed  stomach.  Various  lens-sys- 
tem gastroscopes  have  been  devised,  which  afford  an  excellent 
view  of  the  walls  of  the  air-inflated  stomach.  The  optical  system, 
however,  interferes  with  the  insertion  of  instruments,  so  that  the 
open-tube  gastroscope  is  required  for  the  removal  of  gastric 
foreign  bodies,  the  palpation  of,  or  sponging  secretions  from, 
gastric  lesions.  The  open-tube  gastroscope  may  be  closed  with 
a  window  plug  (Fig.  6)  having  a  rubber  diaphragm  with  a  central 
perforation  for  forceps,  when  it  is  desired  to  inflate  the  stomach. 

Technic. — Relaxation  by  general  anesthesia  permits  lateral 
displacement  of  the  dome  of  the  diaphragm  along  with  the  esopha- 
gus, and  thus  makes  possible  a  wider  range  of  motion  of  the  distal 
end  of  the  gastroscope.  All  of  the  recent  gastroscopies  in  the 
Bronchoscopic  Clinic,  however,  have  been  performed  without 
anesthesia.  The  method  of  introduction  of  the  gastroscope 
through  the  esophagus  is  precisely  the  same  as  the  introduction  of 
the  esophagoscope  (q.v.).  It  should  be  emphasized  that  with 
the  lens-system  gastroscopes,  the  tube  should  be  introduced 
into  the  stomach  under  direct  ocular  guidance,  without  a  mandrin, 
and  the  optical  apparatus  should  be  inserted  through  the  tube  only 
after  the  stomach  has  been  entered.  Blind  insertion  of  a  rigid 
metallic  tube  into  the  esophagus  is  an  extremely  dangerous 
procedure. 

18  273 


274  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

The  descriptions  and  illustrations  of  the  stomach  in  anatomical 
works  must  be  disregarded  as  cadaveric.  In  the  living  body,  the 
empty  stomach  is  usually  found,  on  endoscopic  inspection,  to  be  a 
collapsed  tube  of  such  shape  as  to  fit  whatever  space  is  available 
at  the  particular  moment,  with  folds  and  rugae  running  in  all 
directions,  the  impression  given  as  to  form  being  strikingly  like 
searching  among  a  mass  of  earth  worms  or  boiled  spaghetti. 
The  color  is  pink,  under  proper  illumination,  if  no  food  is  present. 
Poor  illumination  may  make  the  color  appear  deep  crimson.  If 
food  is  present,  or  has  just  been  regurgitated,  the  color  is  bright 
red.  To  appreciate  the  appearance  of  gastritis,  the  eye  must  have 
been  educated  to  the  endoscopic  appearances  under  a  degree  of 
illumination  always  the  same.  The  left  two-thirds  of  the  stomach 
is  most  easily  examined.  The  stomach  wall  can  be  pushed  by  the 
tube  into  almost  any  position,  and  with  the  aid  of  gentle  external 
abdominal  manipulation  to  draw  over  the  pylorus  it  is  possible  to 
examine  directly  almost  all  of  the  gastric  walls  except  the  pyloric 
antrum,  which  is  reachable  in  relatively  few  cases.  A  lateral 
motion  of  from  lo  to  17  cm.  can  be  imparted  to  the  gastroscope, 
provided  the  diaphragmatic  musculature  is  relaxed  by  deep  anes- 
thesia. The  stomach  is  explored  by  progressive  traverse.  That 
is,  after  exploring  down  to  the  greater  curvature,  the  tube-mouth 
is  moved  laterally  about  2  centimeters,  and  the  withdrawing 
travel  explores  a  new  field.  Then  a  lateral  movement  affords  a 
fresh  field  during  the  next  insertion.  This  is  repeated  until  the 
entire  explorable  area  has  been  covered.  Ballooning  the  stomach 
with  air  or  oxygen  is  sometimes  helpful,  but  the  distension  fixes 
the  stomach,  lessens  the  mobility  of  the  arch  of  the  diaphragm, 
and  thus  lessens  the  lateral  range  of  gastroscopic  vision.  Further- 
more, ballooning  pushes  the  gastric  walls  far  away  from  the  reach 
of  the  tube-mouth.  A  window  plug  (Fig.  6)  is  inserted  into  the 
ocular  end  of  the  gastroscope  for  the  ballooning  procedure. 


GASTROSCOPY 


275 


Like  many  other  valuable  diagnostic  means,  gastroscopy  is 
very  valuable  in  its  positive  findings.  Negative  results  are 
entitled  to  little  weight  except  as  to  the  explorable  area. 

The  gastroscopist  working  in  conjunction  with  the  abdominal 
surgeon  should  be  able  to  render  him  invaluable  assistance  in  his 
work  on  the  stomach.  The  surgeon  with  his  gloved  hand  in  the 
abdomen,  by  manipulating  suspected  areas  of  the  stomach  in 
front  of  the  tube-mouth  can  receive  immediately  a  report  of  its 
interior  appearance,  whether  cancerous,  ulcerated,  hemorrhagic, 
etc. 

Lens-system  ballooning  gastroscopy  may  possibly  afford  addi- 
tional information  after  all  possible  data  from  open-tube  gastros- 
copy has  been  obtained.  Care  must  be  exercised  not  to  exert  an 
injurious  degree  of  air-pressure.  The  distended  portion  of  the 
stomach  assumes  a  funnel-like  form  ending  at  the  apex  in  a  depres- 
sion with  radiating  folds,  that  leads  the  observer  to  think  he  is 
looking  at  the  pylorus.  The  foreshortening  produced  by  the  lens 
system  also  contributes  to  this  illusion.  The  best  lens-system 
gastroscope  is  that  of  Henry  Janeway,  which  combines  the  open- 
tube  and  the  lens  system. 

Gastroscopy  for  Foreign  Bodies. — The  great  majority  of  foreign 
bodies  that  reach  the  stomach  unassisted  are  passed  per  rectum, 
provided  the  natural  protective  means  are  not  impaired  by  the 
administration  of  cathartics,  changes  in  diet,  etcetera.  This, 
however,  does  not  mean  that  esophageal  foreign  bodies  should  be 
pushed  into  the  stomach  by  blind  methods,  or  by  esophagoscopy, 
because  a  swallowed  object  lodged  in  the  esophagus  can  always  be 
returned  through  the  mouth.  Foreign  bodies  in  the  stomach  and 
intestines  should  be  fiuoroscopically  watched  each  second  day. 
If  an  object  is  seen  to  lodge  five  days  in  one  location  in  the  intes- 
tines, it  should  be  removed  by  laparotomy,  since  it  will  almost 
certainly  perforate.     Certain  objects  reaching  the  stomach  may 


276  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

be  judged  too  large  to  pass  the  pylorus  and  intestinal  angles. 
These  should  be  removed  by  gastroscopy  when  such  decision  is 
made.  It  is  to  be  remembered  that  gastric  foreign  bodies  may  be 
regurgitated  and  may  lodge  in  the  esophagus,  whence  they  are 
easily  removed  by  esophagoscopy.  The  double-planed  fluoro- 
scope  of  Manges  is  helpful  in  the  removal  of  gastric  foreign  bodies, 
but  there  is  great  danger  of  injury  to  the  stomach  walls,  and  even 
the  peritoneum,  unless  forceps  are  used  with  the  utmost  caution. 


CHAPTER  XXXVI 
ACUTE  STENOSIS  OF  THE  LARYNX 

Etiology. — Causes  of  a  relatively  sudden  narrowing  of  the 
lumen  of  the  larynx  and  subjacent  trachea  are  included  in  the 
following  list.     Two  or  more  may  be  combined. 

1.  Foreign  body. 

2.  Accumulation  of  secretions  or  exudate  in  the  lumen. 

3.  Distension  of  the  tissues  by  air,  inflammatory  products, 
serum,  pus,  etc. 

4.  Displacement  of  relatively  normal  tissues,  as  in  abductor 
paralysis,  congenital  laryngeal  stridor,  etcetera. 

5.  Neoplasms. 

6.  Granulomata. 

Edema  of  the  larynx  may  be  at  the  glottic  level,  or  in  the  supra- 
glottic  or  subglottic  regions.  The  loose  cellular  tissue  is  most 
frequently  concerned  in  the  process  rather  than  the  mucosal 
layer  alone.  In  children  the  subglottic  area  is  very  vascular, 
and  swelling  quickly  results  from  trauma  or  inflammation,  so 
that  acute  stenosis  of  the  larynx  in  children  commonly  has  its 
point  of  narrowing  below  the  cords.  Dyspnea,  and  croupy, 
barking,  cough  with  no  change  in  the  tone  or  pitch  of  the  speaking 
voice  are  characteristic  signs  of  subglottic  stenosis.  Edema  may 
accompany  inflammation  of  either  the  superficial  or  deep  struc- 
tures of  the  larynx.  The  laryngeal  lesion  may  be  primary,  or 
may  complicate  general  diseases;  among  the  latter,  typhoid  fever 
deserves  especial  mention. 

Acute  laryngeal  stenosis  complicating  typhoid  fe^er  is  frequently 
overlooked  and  often  fatal,  for  the  asthenic  patient  makes  no 
fight  for  air,  and  hoarseness,  if  present,  is  very  slight.  The  laryn- 
geal lesion  may  be  due  to  cordal  immobility  from  either  paralysis 

277 


278  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

or  intlammatory  arytenoid  fixation,  in  the  absence  of  edema. 
Perichondritis  and  chondritis  of  the  laryngeal  cartilages  often 
follow  typhoid  ulceration  of  the  larynx,  chronic  stenosis  resulting. 

Laryngeal  stenosis  in  the  newborn  may  be  due  to  various 
anomalies  of  the  larynx  or  trachea,  or  to  traumatism  of  these 
structures  during  delivery.  The  normal  glottis  in  the  newborn 
is  relatively  narrow,  so  that  even  slight  encroachment  on  its 
lumen  produces  a  serious  degree  of  dyspnea.  The  characteristic 
signs  are  inspiratory  indrawing  of  the  supraclavicular  fossae,  the 
suprasternal  notch,  the  epigastrium,  and  the  lower  sternum  and 
ribs.  Cyanosis  is  seen  at  first,  later  giving  place  to  pallid  asphyxia 
when  cardiac  failure  occurs.  Little  air  is  heard  to  enter  the  lungs, 
during  respiratory  efforts  and  the  infant,  becoming  exhausted  by 
the  great  muscular  exertion,  soon  ceases  to  breathe.  Paralytic 
stenosis  of  the  larynx  sometimes  follows  difficult  forceps  deliveries 
during  which  stretching  or  compression  of  the  recurrent  nerves 
occur. 

Acute  laryngeal  stenosis  in  infants,  from  laryngeal  perichondritis, 
may  be  a  delayed  result  of  traumatism  to  the  laryngeal  cartilages 
during  delivery.  The  symptoms  usually  develop  within  four 
weeks  after  birth.  Lues  and  tuberculosis  are  possible  factors  to 
be  eliminated  by  the  usual  methods. 

Surgical  Treatment  of  Acute  Laryngeal  Stenosis. — Multiple 
puncture  of  acute  inflammatory  edema,  while  readily  performed 
with  the  laryngeal  knife  used  through  the  direct  laryngoscope, 
is  an  uncertain  measure  of  relief.  Tracheotomy,  if  done  low  in  the 
neck,  will  completely  relieve  the  dyspnea.  By  its  therapeutic 
effect  of  rest,  it  favors  the  rapid  subsidence  of  the  inflammation 
in  the  larynx  and  is  the  treatment  to  be  preferred.  Intubation  is 
treacherous  and  unreliable  except  in  diphtheritic  cases;  but  in 
the  diphtheritic  cases  it  is,  ideal,  if  constant  skilled  watching  can 
be  had. 


CHAPTER  XXXVII 
TRACHEOTOMY 

Indications. — Tracheotomy  is  indicated  in  dyspnea  of  laryngo- 
tracheal origin.     The  cardinal  signs  of  this  form  of  dyspnea  are: 

1.  Indrawing  at  the  suprasternal  notch. 

2.  Indrawing  around  the  clavicles. 

3.  Indrawing  of  the  intercostal  spaces. 

4.  Restlessness. 

5.  Choking  and  waking  as  soon  as  the  aid  of  the  voluntary 
respiratory  muscles  ceases  in  falling  to  sleep. 

6.  Cyanosis  is  a  dangerously  late  symptom. 

As  a  therapeutic  measure  in  diseases  of  the  larynx  its  place 
has  been  thoroughly  established.  Marked  improvement  of  the 
laryngeal  lesions  has  been  observed  to  follow  tracheotomy  in 
advanced  laryngeal  tuberculosis,  and  in  cancer  of  the  larynx.  It 
has  proven,  in  some  cases,  a  useful  adjunct  in  the  treatment  of 
luetic  laryngitis,  though  it  cannot  be  regarded  as  indicated,  in  the 
absence  of  dyspnea.  Perichondritis  and  other  inflammations  are 
benefited  by  tracheotomy.  A  marked  therapeutic  effect  on 
multiple  laryngotracheal  papillomata  in  children  has  been  noted 
by  the  author  in  hundreds  of  cases. 

Tracheotomy  for  foreign  body  is  no  longer  indicated  either  for 
the  removal  of  the  intruder,  or  for  the  insertion  of  the  broncho- 
scope. Tracheotomy  may  be  urgently  indicated  for  foreign  body 
dyspnea,  but  not  for  foreign  body  removal. 

Subcutaneous  rupture  of  the  trachea  from  external  trauma  may 
produce  dyspnea  and  generalized  emphysema,  both  of  which  will 

be  relieved  by  tracheotomy. 

279 


28o  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

Acromegalic  stenosis  of  the  larynx  is  a  rare  but  urgent  indication 
for  tracheotomy. 

Contraindications. — There  are  no  contraindications  to  trache- 
otomy for  dyspnea. 

The  instruments  required  for  an  orderly  tracheotomy  are: 

Headlight  Curved  needles 

Scalpels  Needle  holder 

2  Retractors  Hypodermic  syringe  for  local 

Trousseau  dilator  anesthesia 

6  Hemostats  No.  i  plain  catgut  ligatures 

Scissors  (dissecting)  Linen  tape 

Tracheal  cannulae  (six  sizes)  Gauze  sponges 

These  are  sterilized  and  kept  in  a  sterile  copper  box  ready  for 
instant  use.  Beside  the  patient's  bed  following  the  tracheotomy 
the  following  sterile  materials  are  placed: 

Sterile  gloves  i  Hemostat 

Sterile  new  gauze  Trousseau  dilator 

Scissors  Duplicate  tracheotomy  tube 

Silver  probe  Basin  of  Bichloride  of  mercury 

solution,  1 :  10,000 

Tracheotomy  is  one  of  the  oldest  operations  known  to  surgery, 
yet  strange  to  say,  it  is  probably  more  often  improperly  performed 
today,  and  more  often  followed  by  needless  mortality,  than  any 
other  operation.  The  two  chief  preventable  sequelae  are  death 
from  improper  routine  surgical  care  and  wrongly  fitted  tube,  and 
stenosis  from  too  high  an  operation.  The  classical  descriptions  of 
crico-thyroidotomy  and  high  and  low  tracheotomy  have  been 
handed  down  to  generations  of  medical  students  without  revision. 
Every  medical  graduate  has  been  taught  that  there  are  two  kinds 
of  tracheotomy,  high  and  low,  the  low  operation  being  very  diffi- 
cult, the  high  operation  very  easy.  When  he  is  suddenly  called 
upon  to  do  an  emergency  tracheotomy,  this  erroneous  teaching 


TRACHEOTOMY  261 

is  about  all  that  remains  in  the  dim  recesses  of  his  memory;  con- 
sequently he  makes  sure  of  doing  the  operation  high  enough,  and 
goes  in  through  the  larynx,  usually  dividing  the  cricoid  cartilage, 
the  only  complete  ring  in  the  trachea.  x\s  originally  made  the 
distinction  between  high  and  low  as  applied  to  tracheotomy 
referred  to  operations  above  and  below  the  isthmus  of  the  thyroid 
gland,  in  a  day  when  primitive  surgery  attached  too  much  impor- 
tance to  operations  upon  the  thyroid  gland.  The  isthmus  is 
entitled  to  absolutely  no  consideration  whatever  in  deciding  the 
location  at  which  to  incise  so  vital  a  structure  as  the  trachea. 
Students  are  taught  different  short  skin  incisions  for  these  two 
operations,  and  it  is  no  wonder  that  they,  as  did  their  prede- 
cessors, find  tracheotomy  a  difficult,  bloody,  and  often  futile 
operation.  The  trachea  is  searched  for  at  the  bottom  of  a  short, 
deep  wound  filled  with  blood,  the  source  of  which  is  difficult  to 
find  and  impossible  to  control. 

Tracheotomic  cannulae  should  be  made  of  sterling  silver.  Ger- 
man silver  plated  with  pure  silver  is  good  enough  for  temporary 
use,  but  the  plating  soon  wears  off  under  the  galvanic  action  set 
up  between  the  two  metals.  Aluminum  becomes  roughened  by 
boiling  and  contact  with  secretions,  and  causes  the  formation  of 
granulations  which  in  time  lead  to  stenosis.  Hard  rubber  tubes 
cannot  be  boiled,  the  walls  are  so  thick  as  to  leave  too  little  lumen, 
and  the  rubber  is  irritating  to  the  tissues.  All  tracheotomy  tubes 
should  be  fitted  with  pilots.  Many  of  the  tubes  furnished  to 
patients  have  no  pilots  to  facilitate  the  introduction,  and  the  tubes 
are  inserted  with  somewhat  the  effect  of  a  cheese  tester,  and  with 
great  pain  and  suffering  on  the  part  of  the  patient.  Most  of  the 
the  tubes  in  the  shops  are  too  short  to  allow  for  the  swelling  of  the 
tissues  of  the  neck  following  the  operation.  They  may  reach  the 
trachea  at  the  time  of  the  operation,  but  as  soon  as  the  reactionary 
swelling  occurs,  the  end  of  the  tube  is  pulled  out  (Fig.  103)  of 


2»2 


BRONCHOSCOPY  AND  ESOPHAGOSCOPY 


the  tracheal  incision;  the  air  hissing  along  the  tube  is  considered 
by  the  attendant  to  indicate  that  the  tube  is  still  in  place,  and  the 


r^ 


Fig.  103. — Schema  showing  thick  pad  of  gauze  dressing,  filling  the  space,  A,  and 
used  to  hold  out  the  author's  full-curved  cannula  when  too  long,  prior  to  reactionary 
swelling,  and  after  subsidence  of  the  latter.  At  the  right  is  shown  the  manner  in 
which  the  ordinary  cannula  of  the  shops  permits  a  patient  to  asphyxiate,  though 
some  air  is  heard  passing  through  the  tracheal  opening,  H,  after  the  cannula  has 
been  partially  withdrawn  by  swelling  of  the  tissues,  T. 


A  B 

Fig.  104. — The  author's  tracheotomic  cannulae.  A,  shows  cane-shaped  cannula 
for  use  in  intrathoracic  compressive  or  other  stenoses.  B,  shows  full  curved  cannula 
for  regular  use.  Pilots  are  made  to  fit  the  outer  cannula;  the  inner  cannula  not  being 
inserted  until  after  withdrawal  of  the  pilot. 

increasing  dyspnea  and  accelerated  respiratory  rate  are  attributed 
to  supposed  pneumonia  or  edema  of  the  lungs,  under  which  errone- 
ous diagnosis  the  patient  is  buried.     In  all  cases  in  which  it  is 


TRACHEOTOMY  283 

reported  that  in  spite  of  tracheotomy  the  dyspnea  was  only  tem- 
porarily relieved,  the  fault  is  the  lack  of  a  "plumber."  That  is, 
an  attendant  who  will  make  sure  that  there  is  at  all  times  a  clear 
airway  all  the  way  down  to  the  lungs.  With  a  bronchoscope 
and  aspirator  he  will  see  that  the  airway  is  clear.  To  begin  with, 
a  proper  sized  cannula  must  be  selected.  The  series  of  different 
sized,  full  curved  tubes,  one  of  which  is  illustrated  in  Fig.  104, 
will  under  all  conditions  reach  the  trachea.  If  the  tube  seems  to 
be  too  long  in  any  given  case,  it  will  usually  be  found  that  the 
tracheotomy  has  been  done  too  high,  and  a  lower  one  should  be 
done  at  once.  If  the  operation  has  not  been  done  too  high,  and 
the  cannula  is  too  long,  a  pad  of  gauze  under  the  shield  will  take 
up  the  surplus  length.  In  cases  of  tracheal  compression  from  new 
growth,  thymus  or  other  such  cases,  in  which  the  ordinary  tube 
will  not  pass  the  obstruction,  the  author's  long  cane-shaped  can- 
nula (see  Fig.  104)  can  be  inserted  past  the  obstruction,  and  if 
necessary  into  either  bronchus.  The  fenestrum  placed  in  the 
cannula  in  many  of  the  older  tubes,  with  the  supposed  function  of 
allowing  partial  breathing  through  the  larynx,  is  a  most  pernicious 
thing.  A  properly  fitted  tube  should  not  take  up  more  than  half 
of  the  cross  section  of  the  trachea,  and  should  allow  the  passage 
of  sufficient  air  for  free  laryngeal  breathing  when  it  is  completely 
corked.  The  fenestrum  is,  moreover,  rarely  so  situated  that  air 
can  pass  through  it;  the  fenestral  edges  act  as  a  constant  irritant 
to  the  wound,  producing  bleeding  and  granulation  tissue. 

Anesthesia. — No  dyspneic  patient  should  be  given  a  general 
anesthetic ;  because  any  patient  dyspneic  enough  to  need  a  trache- 
otomy for  dyspnea  is  depending  largely  upon  the  action  of  the 
accessory  respiratory  muscles.  When  this  action  is  stopped  by 
beginning  unconsciousness,  respiration  ceases.  If  the  trachea  is 
not  immediately  opened,  artificial  respiration  instituted,  and 
oxygen  insufflated,  the  patient  dies  on  the  table.     Skin  infiltra- 


284  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

tion  along  the  line  of  incision  with  a  very  weak  cocaine  solution 
(Ho  of  I  per  cent),  apothesine  (2  per  cent),  novocaine,  Schleich's 
fluid  or  other  local  anesthetic,  suffices  to  render  the  operation 
painless.  The  deeper  structures  have  little  sensation  and  do  not 
require  infiltration.  It  has  been  advocated  that  an  interannular 
injection  of  cocaine  solution  with  a  hypodermic  syringe  be  done 
just  prior  to  incision  of  the  trachea  for  the  purpose  of  preventing 
cough  after  the  incision  of  the  trachea  and  the  insertion  of  the 
cannula.  It  would  seem,  however,  that  this  introduces  the  risk  of 
aspiration  pneumonia  and  pulmonary  abscess,  by  permitting  the 
aspiration  and  clotting  of  blood  in  small  bronchi,  followed  by 
subsequent  breaking  down  of  the  clots.  As  the  author  has  so 
often  said,  "The  cough  reflex  is  the  watch  dog  of  the  lungs,'^ 
and  if  not  drugged  asleep  by  local  or  general  anesthesia  can  safely 
be  relied  upon  to  prevent  all  possibility  of  the  blood  or  the  pus 
which  nearly  always  is  present  in  acute  or  chronic  conditions 
calling  for  tracheotomy,  being  aspirated  into  the  deeper  air- 
passages.  Cocaine  in  any  form,  by  any  method,  and  in  any 
dosage,  is  dangerous  in  very  young  children. 

Technic. — The  patient  should  be  placed  in  the  recumbent 
position,  with  the  extended  head  held  in  the  midhne  by  an  assist- 
ant. The  shoulders,  not  the  neck,  should  be  slightly  raised  with 
a  sand  bag.  The  head  should  be  somewhat  lower  than  the  feet, 
to  lessen  the  danger  of  aspiration  of  blood.  A  midline  incision 
dividing  the  skin  and  fascia  is  made  from  the  thyroid  notch  to 
just  above  the  suprasternal  notch.  The  cricoid  is  now  located, 
and  the  deeper  dissection  is  continued  from  below  this  point.  The 
ribbon  muscles  are  separated  with  dissecting  scissors  or  knife, 
and  held  apart  with  retractors.  If  the  isthmus  of  the  thyroid 
gland  is  in  the  way,  it  may  be  retracted  upward;  if  large,  however, 
it  should  be  divided  and  ligated,  for  it  is  apt  to  slip  over  the  tra- 
cheal incision  afterward,  and  render  difficult  the  quick  finding 


TRACHEOTOMY  285 

of  the  incision  during  after-care.  This  covering  of  the  tracheal 
incision  by  the  sHpping  back  of  the  drawn-aside  thyroidal  isthmus 
is  one  of  the  most  frequent  avoidable  causes  of  mortality,  because 
it  deflects  the  cannula  off  into  the  tissues  when  it  is  replaced  after 
cleaning  during  the  early  postoperative  period.  The  corrugated 
surface  of  the  trachea  can  be  felt,  and  its  exact  location  can  be 
determined  by  the  index  finger.  If  the  tracheotomy  is  proceeding 
in  an  orderly  manner,  all  bleeding  points  should  be  caught  and  tied 
with  plain  catgut  (No.  i)  before  the  trachea  is  opened.  Because 
of  distension  of  vessels  during  cough,  all  but  the  tiniest  vessels 
should  be  ligated.  Side-cut  veins  are  particularly  treacherous. 
They  should  be  freed  of  tissue,  cut  across  and  the  divided  ends 
ligated. 

The  incision  in  the  trachea  should  be  as  low  as  possible,  and 
should  never  be  made  through  the  first  ring.  The  incision  should 
be  through  the  third,  fourth  and  fifth  rings.  Only  in  cases  of 
laryngoptosis  will  it  be  necessary  to  incise  the  trachea  higher  than 
this.  The  incision  must  be  made  in  the  midline,  and  in  the  long 
axis  of  the  trachea,  and  care  must  be  exercised  that  the  point  of 
the  knife  does  not  perforate  the  posterior  tracheal  wall.  Stab 
incisions  are  always  to  be  avoided.  If  the  incision  in  the  trachea 
is  found  to  be  of  insufficient  length,  the  original  incision  must  be 
found  and  elongated.  A  second  incision  must  not  be  made,  for 
the  portion  of  cartilage  between  the  two  incisions  will  die  and  will 
almost  certainly  make  a  site  of  future  tracheal  stenosis.  The 
cricoid  should  never  be  cut,  for  stenosis  is  almost  sure  to  follow 
the  wearing  of  a  cannula  in  this  position.  A  Trousseau  dilator 
should  now  be  inserted  in  the  tracheal  incision,  its  blades  gently 
separated.  With  the  tracheal  lumen  thus  opened,  a  cannula  of 
proper  size  is  introduced  with  absolute  certainty  of  its  having 
entered  the  trachea.  A  quadruple-folded  square  of  gauze  in  the 
form  of  a  pad  about  four  inches  square  is  moistened  with  mercuric 


286 


BRONCHOSCOPY  AND  ESOPHAGOSCOPY 


chloride  solution  (i:io,ooo)  and  is  slit  from  the  lower  border  to 
its  midpoint.  This  pad  is  slipped  from  above  downward  under 
the  tape  holder  of  the  cannula,  the  slit  permitting  the  tubal 
part  of  the  cannula  to  reach  the  central  part  of  the  pad  (Fig.  io8), 
and  completely  covers  the  wound.     No  attempt  should  be  made 


14- 

Sternal  notch 
Fig.  105. — Schema  of  practical  gross  anatomy  to  be  memorized  for  emergency- 
tracheotomy.  The  middle  line  is  the  safety  line,  the  higher  the  wider.  Below,  the 
safety  line  narrows  to  the  vanishing  point  VP.  The  upper  limit  of  the  safety  line  is 
the  thyroid  notch  until  the  trachea  is  bared,  when  the  limit  falls  below  the  first 
tracheal  ring.  In  practice  the  two-dark  danger  lines  are  pushed  back  with  the  left 
thumb  and  middle  finger  as  shown  in  Fig.  106,  thus  throwing  the  safety  line  into 
prominence.     This  is  generally  known  as  Jackson's  tracheotomic  triangle. 


to  suture  the  skin  wound,  for  this  tends  to  form  a  pocket  in  which 
lodge  the  bronchial  secretions  that  escape  alongside  the  tube, 
resulting  in  infection  of  the  wound.  Furthermore  it  renders  the 
daily  changing  of  the  tube  much  more  difficult.  In  fact  it  prevents 
the  attendant  from  being  certain  that  the  tube  is  actually  placed 
in   the   trachea.     Suturing   of   the   skin   to   the   trachea   should 


TRACHEOTOMY 


287 


never  be  done,  for  the  sutures  soon  tear  out  and  often  set  up  a 
perichondritis  of  the  tracheal  cartilages,  with  resulting  diflEicult 
decannulation. 

Emergency  Tracheotomy. — Stabbing  of  the  cricothyroid  mem- 


\ 


Fig.  106.^ — -Schema  showing  the  author's  method  of  rapid  tracheotomy.  First 
stage.  The  hands  are  drawn  ungloved  for  the  sake  of  clearness.  The  upper  hand 
is  the  left,  of  which  the  middle  finger  (M)  and  the  thumb  are  used  to  repress  the 
sterno-cleido-mastoid  muscles,  the  finger  and  thumb  being  close  to  the  trachea  in 
order  to  press  backward  out  of  the  way  the  carotid  arteries  and  the  jugular  vein. 
This  throws  the  trachea  forward  into  prominence,  and  one  deep  slashing  cut  will 
incise  all  of  the  soft  tissues  down  to  the  trachea. 

brane,  or  an  attempted  stabbing  of  the  trachea,  so  long  taught  as  an 
emergency  tracheotomy,  is  a  mistake.  The  author's  "two 
stage,  finger  guided"  method  is  safer,  quicker,  more  efficient, 
and  not  likely  to  be  followed  by  stenosis.  To  execute  this 
promptly,  the  operator  is  required  to  forget  his  textbook  anatomy 


265  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

and  memorize  the  schema  (Fig.  105).  The  larynx  and  trachea 
are  steadied  by  the  thumb  and  middle  finger  of  the  left  hand, 
which  at  the  same  time  push  back  the  important  nerves  and 
vessels  which  parallel  the  trachea,  and  render  the  central  safety 
line  more  prominent  (Fig.  106).     A  long  incision  is  now  made 


Fig.  107. — Illustrating  the  author's  method  of  quick  tracheotomy.  Second 
stage.  The  fingers  are  drawn  ungloved  for  the  sake  of  clearness.  In  operating  the 
whole  wound  is  full  of  blood,  and  the  rings  of  the  trachea  are  felt  with  the  left  index 
which  is  then  moved  slightly  to  the  patient's  left,  while  the  knife  is  slid  down  along 
the  left  index  to  exactly  the  middle  line  when  the  trachea  is  incised. 

from  the  thyroid  notch  almost  to  the  suprasternal  notch,  and 
deep  enough  to  reach  the  trachea.  This  completes  the  first  stage. 
Second  stage.  The  entire  wound  is  full  of  blood  and  the 
trachea  cannot  be  seen,  but  its  corrugations  can  be  very  readily 
felt  by  the  tip  of  the  free  left  index  finger.  The  left  index  finger 
is  now  moved  a  little  to  the  patient's  left  in  order  that  the  knife 


TRACHEOTOMY 


289 


shall  come  precisely  in  the  midline  of  the  trachea,  and  three  rings 
of  the  trachea  are  divided  from  above  downward  (Fig.  107). 
The  Trousseau  dilator  should  now  be  inserted,  the  head  of  the 
table  should  be  lowered,  and  the  patient  should  be  turned  on  the 
side  to  allow  the  blood  to  run  away  from  the  wound.  If  respira- 
tion has  ceased,  a  cannula  is  slipped  in,  and  artificial  respiration 
is  begun.  Oxygen  insufflation  will  aid  in  the  restoration  of  respira- 
tion, and  a  pearl  of  amyl  nitrite  should  be  crushed  in  gauze  and 
blown  in  with  the  oxygen.  In  all  such  cases,  excessive  pressure 
of  oxygen  should  be  avoided  because  of  the  danger  of  producing 
ischemia  of  the  lungs.  Hope  of  restoring  respiration  should 
not  be  abandoned  for  half  an  hour  at  least.  One  of  the  author's 
assistants,  Dr.  Phillip  Stout, 
saved  a  patient's  life  by  keep- 
ing up  artificial  respiration  for 
twenty  minutes  before  the 
patient  could  do  his  own 
breathing. 

The  after-care  of  the  tracheo- 
tomic  wound  is  of  the  utmost 
importance.  A  special  day  and 
night  nurse  are  required.  The 
inner  tube  of  the  cannula  must 
be  removed  and  cleaned  as  soon 
as  it  contains  secretion.  Secre- 
tion coughed  out  must  be  wiped 
away  quickly,  but  gently,  before  it  is  again  aspirated.  The 
gauze  dressing  covering  the  wound  must  be  changed  as  soon  as 
soiled  with  secretions  from  the  wound  and  the  air-passages.  Each 
fresh  pad  should  be  moistened  with  very  weak  bichloride  of  mer- 
cury solution  (i :  1 0,000).  The  outer  tube  must  be  changed  every 
twenty-four  hours,  and  oftener  if  the  bronchial  secretion  is  abun- 

19     . 


Fig.  108. — Method  of  dressing  a 
tracheotomic  wound.  A  broad  quad- 
ruple, in-folded  pad  of  gauze  is  cut  to 
its  centre  so  that  it  can  be  slipped 
astride  of  the  tube  of  the  cannula  back 
of  the  shield.  No  strings,  ravellings  or 
strips  of  gauze  are  permissible  because 
of  the  risk  of  their  getting  down  into 
the  trachea. 


290  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

dant.  Student-physicians  who  have  been  taught  my  methods  and 
who  have  seen  the  cases  in  care  of  our  nurses  have  often  expressed 
amazement  at  the  neglect  unknowingly  inflicted  on  such  cases 
elsewhere,  in  the  course  of  ordinary  routine  surgery.  It  is  not 
unusual  for  a  patient  to  be  sent  to  the  Bronchoscopic  Clinic  who 
has  worn  his  cannula  without  a  single  changing  for  one  or  two 
years.  In  some  cases  the  tube  had  broken  and  a  portion  had  been 
aspirated  into  the  trachea. 

If  the  respiratory  rate  increases,  instead  of  attributing  it  to 
pulmonary  complications,  the  entire  cannula  should  be  removed, 
the  wound  dilated  with  the  Trousseau  forceps,  the  interior  of  the 
trachea  inspected,  and  all  secretions  cleaned  away.  Then  the 
tracheal  mucosa  below  the  wound  should  be  gently  touched  with  a 
sterile  bent  probe,  to  induce  cough  to  rid  the  lower  air  passages 
of  accumulated  secretions.  In  many  cases  it  is  a  life-saving 
procedure  to  insert  a  sterile  long  malleable  aspirating  tube  to 
remove  secretions  from  the  lower  air-passages.  When  all  is  clear, 
a  fresh  sterile  cannula  which  has  been  carefully  inspected  to  see 
that  its  lumen  has  been  thoroughly  cleaned,  is  inserted,  and  its 
tapes  tied.  Good  "plumbing,"  that  is,  the  maintenance  at  all 
times  of  a  clear,  clean  passage  in  all  the  "pipes,"  natural  and 
artificial,  is  the  reason  why  the  mortality  in  the  Bronchoscopic 
Clinic  has  been  less  than  half  of  one  per  cent,  while  in  ordinary 
routine  surgical  care  in  all  hospitals  collectively  it  ranges  from  10 
to  20  per  cent. 

Bronchial  Aspiration. — As  mentioned  above,  bronchial  aspira- 
tion is  often  necessary.  When  the  patient  is  unable  to  get  up 
secretions,  he  will,  as  demonstrated  by  the  author  many  years 
ago,  "drown  in  his  own  secretions."  In  some  cases  bronchoscopic 
aspiration  is  required  (Peroral  Endoscopy,  p.  483).  Occasionally, 
very  thick  secretions  will  require  removal  with  forceps.  Pus 
may  become  very  thick  and  gummy  from  the  administration  of 


TRArHEOTOMY  29I 

morphin.  Opiates  do  not  lessen  pus  formation,  but  they  do  lessen 
the  normal  secretions  that  ordinarily  increase  the  quantity  and 
fluidity  of  the  pus.  When  to  this  is  added  the  dessicating  efifect 
of  the  air  inhaled  through  the  cannula,  unmoistened  by  the  upper 
air-passages,  the  secretions  may  be  so  thick  as  to  form  crusts 
and  plugs  that  are  equivalent  to  foreign  bodies  and  require  removal 
with  forceps.  Diphtheritic  membrane  in  the  trachea  may  require 
removal  with  bronchoscope  and  forceps.  Thinner  secretions  may 
be  removed  by  sponge-pumping.  In  most  cases,  however,  secre- 
tions can  be  brought  up  through  an  aspirating  tube,  connected  to 
a  bronchoscopic  aspirating  syringe  (Fig.  ii),  an  ordinary  aspir- 
ating bottle,  or  preferably,  a  mechanical  aspirator  such  as  that 
shown  in  Fig.  12.  In  this,  combined  with  bronchoscopic  oxygen 
insufflation  (q.v.),  we  have  a  life-saving  measure  of  the  highest 
efiiciency  in  cases  of  poisoning  by  chlorine  and  other  irritant  and 
asphyxiating  gases.  An  aspirating  tube  for  insertion  into  the 
deeper  air  passages  should  be  of  copper,  so  that  it  can  be  bent  to 
the  proper  curve  to  reach  into  the  various  parts  of  the  tracheobron- 
chial tree,  and  it  should  have  a  removable  copper-wire  core  to 
prevent  kinking,  and  collapse  of  the  lumen.  The  distal  end  should 
be  thickened,  and  also  perforated  at  the  sides,  to  prevent  drawing- 
in  of  the  mucosa  and  trauma  thereto.  A  rubber  tube  may  be  used, 
but  is  not  so  satisfactory.  The  one  shown  in  Fig.  10  I  had  made 
by  Mr.  Pilling,  and  it  has  proved  very  satisfactory. 

Decannulation. — When  the  tracheal  incision  is  placed  below 
the  first  ring,  no  difficulty  in  decannulation  should  result  from  the 
operation  per  se.  When  by  temporarily  occluding  the  cannula 
with  the  finger  it  is  evident  that  the  laryngeal  aperture  has 
regained  sufficient  size  to  allow  free  breathing,  a  smaller-sized 
tracheotomic  tube  should  be  substituted  to  allow  free  passage  of 
air  around  the  cannula  in  the  trachea.  In  doing  this,  the  amount 
of  secretion  and  the  handicap  of  impaired  glottic  mobility  in  the 


292  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

expulsion  of  thick  secretions  must  be  borne  in  mind.  Babies 
labor  under  a  special  handicap  in  their  inefficient  bechic  expulsion 
and  especially  in  their  small  cannulae  which  are  so  readily  occluded. 
If  breathing  is  not  free  and  quiet  with  the  smaller  tube,  the 
larger  one  must  be  replaced.  If,  however,  there  is  no  trouble  with 
secretions,  and  the  breathing  is  free  and  quiet,  the  inner  cannula 
should  be  removed,  and  the  external  orifice  of  the  outer  cannula 
firmly  closed  with  a  rubber  cork.  If  the  laryngeal  condition  has 
been  acute,  decannulation  can  usually  be  safely  done  after  the 
patient  has  been  able  to  sleep  quietly  for  three  nights  with  a 
corked  cannula.  If  free  breathing  cannot  be  obtained  when  the 
cannula  is  corked,  the  larynx  is  stenosed,  and  special  work  will  be 
required  to  remove  the  tube.  Children  sometimes  become  panic 
stricken  when  the  cannula  is  completely  corked  at  once  and  they 
are  forced  to  breathe  through  the  larynx  instead  of  the  easier  short- 
cut through  the  neck.  In  such  a  case,  the  first  step  is  partially  to 
cork  the  cannula  with  a  half  or  two-thirds  plug  made  from  a  pure 
rubber  cord  fashioned  in  the  desired  shape  by  grinding  with  an 
emery  wheel  (Fig.  112).  Thus  the  patient  is  gradually  taught  to 
use  the  natural  air- way,  still  feeling  that  he  has  an  "anchor  to 
windward  "  in  the  opening  in  the  cannula.  When  some  swelling  of 
the  laryngeal  structures  still  exists,  this  gradual  corking  has  a 
therapeutic  effect  in  lessening  the  stenosis  by  exercising  the  muscles 
of  abduction  of  the  cords  and  mobilizing  the  cricoarytenoid  articu- 
lation during  the  inspiratory  effort.  The  forced  respiration  keeps 
the  larynx  freed  from  secretions,  which  are  more  or  less  purulent 
and  hence  irritating.  After  removing  the  cannula,  in  order  that 
healing  may  proceed  from  the  bottom  upward,  the  wound  should 
be  dressed  in  the  following  manner:  A  single  thickness  of  gauze 
should  be  placed  over  the  wound  and  the  front  of  the  neck,  and  a 
gauze  wedge  firmly  inserted  over  this  to  the  depths  of  the  tracheo- 
tomic  wound,  all  of  this  dressing  being  held  in  place  by  a  bandage. 


TRACHEOTOMY 


293 


If  the  skin-wound  heals  before  the  fibrous  union  of  the  tracheal 
cartilages  is  complete,  exuberant  granulations  are  apt  to  form  and 
occlude  the  trachea,  perhaps  necessitating  a  new  tracheotomy  for 
dyspnea. 

It  is  so  important  to  fix  indelibly  in  the  mind  the  cardinal 
points  concerning  tracheotomy  that  I  have  appended  to  this 
chapter  the  teaching  notes  that  I  have  been  for  years  giving  my 
classes  of  students  and  practitioners,  hundreds  of  whom  have 
thanked  me  for  giving  them  the  clear-cut  conception  of  tracheot- 
omy that  enabled  them,  when  their  turn  came  to  do  an  emerg- 
ency tracheotomy,  to  save  human  life. 


RESUME  OF  TRACHEOTOMY 

Instruments. 

Headlight 

Sandbag  , 

Scalpel 

Hemostats 

Small  retractors 

Tenaculum 

Tracheotomic  cannulae  (proper  kind) 

Tracheobronchial  aspirator. 

Probe. 

Tapes  for  cannulae 

Trousseau  dilator 

Sponges 

Infiltration  syringe  and  solution 

Oxygen  tank. 
Indications:  Laryngeal  dyspnea. 

(Indrawing  guttural  and  clavicular  fossae  and  at  epigastrium. 

Pallor.     Restlessness.     Drowning  in  his  own  secretions.)    . 
Do  it  early.     Don't  wait  for  cyanosis. 


Long. 

Half  area  cross- 
section  trachea 

Proper  curve: 
Radius  too  short 
will  press  ant. 
tracheal  wall; 
too  long,  post, 
wall. 

Sterling  silver. 


294  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

Never  use  general  anesthesia  on  dyspneic  patient. 

Forget    about  "high"  and  "low"  distinctions  until  trachea  is 

exposed. 
Memorize  Jackson's  tracheotomic  triangle. 
Patient  recumbent,  sand  bag  under  shoulders  or  neck.     Nose  to 

zenith. 
Infiltration,  Intradermatic. 
Incise  from  Adam's  apple  to  guttural  fossa. 
Hemostasis. 
Keep  in  middle  line. 
Feel  for  trachea. 

Expose  isthmus  of  thyroid  gland. 
Draw  it  upward  or  downward  or  cut  it. 
Ligature,  torsion,  etc.  before  incising  trachea. 
Hold  trachea  with  tenaculum. 
Incise  trachea  below  first  ring. 

Avoid  cutting  cricoid  or  first  ring.     Cut  3  rings  vertically. 

Don't  hack.     Don't  cut  posterior  wall  which  almost  touches 
the  anterior  wall  during  cough.     Spread  carefully,  with 
Trousseau  dilator. 
Insert  cannula;  see  it  enter  tracheal  lumen;  remove  pilot;  tie  tapes. 
Don't  suture  wound.     Dress  with  large  squares. 
Don't  give  morphine. 
Decannulation  by  corking  partially,  after  changing  to  smaller 

cannula. 
Do  not  remove  cannula  permanently  until  patient  sleeps  without 

indrawing  with  corked  cannula. 

RESUMfi  OF  EMERGENCY  TRACHEOTOMY 

The  following  notes  should  be  memorized. 
I.  Essentials:   Knife   and  pair   of  hands   (but   full   equipment 
better) . 


TRACHEOTOMY  295 

2.  Don't  do  a  laryngotomy,  or  stabbing. 

3.  ''Two  stage,  finger  guided"  operation  better. 

4.  Sand  bag  or  substitute. 

5.  Press  back  danger  lines  with  left  thumb  and  middle  finger, 

making  safety  line  and  trachea  prominent. 

6.  Memorize  Jackson's  tracheotomic  triangle. 

7.  Incise  exactly  in  middle  line  from  Adam's  apple  to  sternum. 

8.  Feel  for  tracheal  corrugations  with  left  index  in  pool  of  blood, 

following  trachea  with  finger  downward  from   superficial 
Adam's  apple. 

9.  Pass  knife  along  index  and  incise  trachea  (not  too  deeply, 

may  cut  posterior  wall). 

10.  Don't  mind  bleeding;  but  keep  middle  line  and  keep  head 

straight;  keep  head  low;  don't  bother  about  thyroid  gland. 

11.  Don't  expect  hiss  when  trachea  is  cut  if  patient  has  stopped 

breathing. 

12.  Start  artificial  respiration. 

13.  Amyl  nitrite.     Oxygen. 

14.  Practice  palpation  of  the  neck  until  the  tracheal  landmarks 

are  familiar. 

15.  Practice  above  technic,   up   to  point  of  incision,   at  every 

opportunity. 

16.  Jackson's  tracheotomic  triangle:  A  triangulation  of  the  front 

of   the   neck  intended   to   facilitate   a  proper   emergency 
tracheotomy. 

Apex  at  suprasternal  notch. 

Sides  anterior  edge  sternomastoids. 

Base  horizontal  line  lower  edge  cricoid. 

RESUMfi  OF  AFTER-CARE  OF  A  TRACHEOTOMIC  CASE 

I.  Always  bear  in  mind  that  tracheotomy  is  not  an  ultimate 
object.     The  ultimate  object  is  to  pipe  air  down  into  the 


296  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

lungs.     Tracheotomy  is  only  a  means  to  that  end. 

2.  Sterile  tray  beside  bed  should  contain  duplicate  (exact)  trach- 

eotomy tube,  Trousseau  dilator,  hemostat,  thumb  forceps, 
silver  probe,  scissors,  scalpel,  probe-pointed  curved  bistoury. 
Sterile  golves  ready. 

3.  Special  nursing  necessary  for  safety. 

4.  Laxative. 

5.  Sponge  away  secretions  before  they  are  drawn  in. 

6.  Cover  wound  with  wide  large  gauze  square  slit  so  it  fits 

around  cannula  under  the  tape  holder.  Pull  off  ravelings. 
Keep  wet  with  i :  10,000  Bichloride  solution. 

7.  Change  dressing  every  hour  or  oftener. 

8.  Abundance  of  fresh  air,  temperature  preferably  about  70°. 

9.  Nurse  should  remove  inner  cannula  as  often  as  needed  and  clean 

it  with  pipe  cleaner  before  boiling. 
ID.  Outer  cannula  should  be  changed  every  day  by  the  surgeon  or 
long-experienced  tracheotomy  nurse.     A  pilot  should  be 
used  and  care  should  be  taken  not  to  injure  the  cut  ends 
of  the  tracheal  cartilage. 

11.  A  sterile,  bent  probe  may  be  inserted  downward  in  the  trachea 

with  both  cannulae  out  to  excite  cough  if  necessary  to  expel 
secretions.  An  aspirating  tube  should  be  used,  when 
necessary. 

12.  A  patient  with  a  properly  fitted  cannula  free  of  secretions 

breathes  noiselessly.  Any  sound  demands  immediate 
attention. 

13.  If  the  respiratory  rate  increase  it  is  much  more  likely  to  be 

due  to  obstruction  in,  malposition  of,  or  shortness  of  the 
cannula  than  to  lung  complications. 

14.  Be  sure  that: 

(a)  The  cannula  is  clear  and  clean. 

(b)  The  cannula  is  long  enough  to  reach  well  down  into 


TRACHEOTOMY  297 

the  trachea.  A  cannula  that  was  long  enough  when 
the  operation  was  done  may  be  too  short  after  the 
cervical  tissues  swell. 
(c)  The  distal  end  of  the  cannula  actually  is  deeply  in 
the  trachea.  The  only  way  to  be  sure  is,  when 
inserting  the  cannula,  to  spread  the  wound  and  the 
tracheal  incision  with  a  Trousseau  dilator,  then  see 
the  interior  of  the  tracheal  lumen  and  see  the  caimula 
enter  therein. 

15.  If  after  attending  to  the  above  mentioned  details  there  are 

still  signs  of  obstructive  dyspnea,  a  bronchoscopy  should  be 
done  for  finding  and  removal  of  the  obstruction  in  the 
trachea  or  main  bronchi. 

16.  If  all  the  "pipes,"    natural  and  instrumental,  are  clear  there 

can  be  no  such  thing  as  obstructive  dyspnea. 

17.  Pneumonia  and  pulmonary  edema  may  exist  before  trache- 

otomy, but  they  are  rare  sequelae. 

18.  Decannulation,  in  cases  of  tracheotomy  done  for  temporary 

conditions  should  not  be  attempted  until  the  patient  has 
slept  at  least  3  nights  with  his  cannula  tightly  corked.  A 
properly  fitted  cannula  {i.e.  one  not  larger  than  half  the  area 
of  cross  section  of  the  trachea)  permits  the  by-passage  of 
plenty  of  air.  A  partial  cork  should  be  worn  for  a  few  days 
first  for  testing  and  ''weaning"  a  child  away  from  the  easier 
breathing  through  the  neck.  In  cases  of  chronic  laryngeal 
stenosis  a  prolonged  test  is  necessary  before  attempting 
decannulation. 

19.  A  tracheotomic  case  may  be  aphonic,  hence  unable  to  call  for 

help. 

20.  The   foregoing  rules   apply   to   the  post-operative  periods. 

After  the  wound  has  healed  and  a  fistula  is  established,  the 
patient,  if  not  a  child,  may  learn  to  care  for  his  own  cannula. 


298  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

21.  Do  not  give  cough-sedatives  or  narcotics.     The  cough  reflex 
is  the  watch  dog  of  the  lungs. 

NOTES  ON  NURSING  TRACHEOTOMIZED  PATIENTS 

Duplicate  cannula  Scalpel 

Trousseau  dilator  Hemostat 

Bedside  tray  should      Dressing  forceps  Sterile  vaseline 

contain:  Scissors  Tape 

Probe  Gauze  sponges 

Probe-pointed  Gauze  squares 
curved  bistoury. 

1.  Room  should  be   abundantly  ventilated,  as  free  from  dust 

and  lint  as  possible,  and  the  air  should  be  moistened  by 
steam  in  winter. 

2.  Keep    mouth    clean.     Tooth    brush.     Rinse    alcohol    1:10. 

3.  Sponge   away   secretion   after   the   cough  before   drawn  in. 

4.  Remove  inner  cannula  (not  outer)  as  often  as  needed.     Not 

less  often  than  every  hour.     Replace  immediately.     Never 
boil  a  cannula  until  you  have  thoroughly  cleaned  it. 

5.  Obstruction  of  cannula   calling  for   cleaning  indicated  by: 

Blue  or  ashy  color. 

Indrawing  at  clavicles,  sternal  notch,  epigastrium. 

Noisy  breathing.     (Learn  sound.) 

6.  Surgeon  (in  our  cases)  will  change  outer  cannula  once  daily 

or  oftener. 

7.  Duplicate  cannulae. 

8.  Be  careful  in  cleaning  cannulae  not  to  damage. 

9.  Watch  for  loose  parts  on  cannula. 

10.  Change  dressing  (in  our  cases)  as  often  as  soiled.     Not  less 

often   than   every   hour.     Large   squares.     Never   narrow 
strips. 

1 1 .  Watch  color  of  lips  and  ears  and  face. 


TRACHEOTOMY  299 

12.  Rcportatonceif  food  or  water  leaks  through  wound.      (Cough- 

ing and  choking). 

13.  Never  leave  a  tracheotomized  patient  unwatched  during  the 

first  days  or  weeks,  according  to  case. 

14.  Remember  Trousseau  dilator  or  hemostat  will  spread  the 

tracheal  wound  or  fistula  when  cannula  is  out. 

15.  Remember  life  depends  on  a  clear  cannula  if  the  patient  gets 

no  air  through  the  mouth. 

16.  Remember  it  takes  very  little  to  clog  the  small  cannula  of  a 

child. 

17.  Remember  a  tracheotomized  patient  cannot  call  for  help. 

18.  Decannulation.     Testing  by  corking  partially.     Watch  corks 

not  too  small,  or  broken.     Attach  them  by  braided  silk 
thread.     Pure  rubber  cord  ground  down  makes  best  cork. 


CHAPTER  XXXVIII 
CHRONIC  STENOSIS  OF  THE  LARYNX  AND  TRACHEA 

The  various  forms  of  laryngeal  stenosis  for  which  tracheotomy 
or  intubation  has  been  performed,  and  the  difficulties  encountered 
in  restoring  the  natural  breathing,  may  be  classified  into  the  follow- 
ing types: 

1.  Panic 

2.  Spasmodic 

3.  Paralytic 

4.  Ankylotic  (arytenoid) 

5.  Neoplastic 

6.  Hyperplastic 

7.  Cicatricial 

(a)  Loss  of  cartilage 

(b)  Loss  of  muscular  tissue 

(c)  Fibrous 

Panic. — Nothing  so  terrifies  a  child  as  severe  dyspnea;  and  the 
memory  of  previous  struggles  for  air,  together  with  the  greater 
ease  of  breathing  through  the  tracheotomic  cannula  than  through 
even  a  normal  larynx,  incites  in  some  cases  so  great  a  degree  of 
fear  that  it  may  properly  be  called  panic,  when  attempts  at  decan- 
nulation  are  made.  Crying  and  possibly  glottic  spasm  increase 
the  difficulties. 

Spasmodic  stenosis  may  be  associated  with  panic,  or  may  be 
excited  by  subglottic  inflammation.  Prolonged  wearing  of  an 
intubation  tube,  by  disturbing  the  normal  reciprocal  equilibrium 
of  the  abductors  and  adductors,  is  one  of  the  chief  causes.  The 
treatment  for  spasmodic  stenosis  and  panic  is  similar.  The  use  of 
a  special  intubation  tube  having  a  long  antero-posterior  lumen 

and  a  narrow  neck,  which  form  allows  greater  action  of  the 

300 


-91  B^-ii  hhmafii  asuftjau  Aioaur}  vi'i./  ii.  v  trcouU     .f.icfinsJr  iii-j; 


-     .uv,..»i  ...  w;r;,^    SHc...  .  .  -,,...-    -._      -    .     -    - 


.  PLATE  V 

Photoprocess  Reproductions  of  the  Author's  Oil-color  Drawings  from  Life — 
Laryngeal  and  Tracheal  Stenoses: 

I,  Indirect  view,  sitting  position;  postdiphtheric  cicatricial  stenosis  permanently 
cured  by  endoscopic  evisceration.  (See  Fig.  5.)  2,  Indirect  view,  sitting  position; 
posttyphoid  cicatricial  stenosis.  Mucosa  was  very  cyanotic  because  cannula  was  re- 
moved for  laryngoscopy  and  bronchoscopy.  Cured  by  laryngostomy.  (See  Fig.  6.)  3, 
Indirect  view,  sitting  position;  posttyphoid  infiltrative  stenosis,  left  arytenoid  destroyed 
by  necrosis.  Cured  by  laryngostomy;  failure  to  form  adventitious  band  (Fig.  7) 
because  of  lack  of  arytenoid  activity.  4,  Indirect  view,  recumbent  position;  post- 
typhoid cicatricial  stenosis.  Cured  of  stenosis  by  endoscopic  e\'isceration  with  sliding 
punch  forceps.  Anterior  commissure  twice  afterward  cleared  of  cicatricial  tissue  as  in 
the  other  case  shown  in  Fig.  15.  Ultimate  result  shown  in  Fig.  8.  5,  Same  patient  as 
Fig.  i;  sketch  made  two  years  after  decannulation  and  plastic.  6,  Same  patient  as 
Fig.  2;  sketch  made  four  years  after  decannulation  and  plastic.  7,  Same  patient  as 
Fig.  3;  sketch  made  three  years  after  decannulation  and  plastic.  8,  Same  patient  as 
Fig.  4;  sketch  made  one  year  after  decannulation,  fourteen  months  after  clearing  of 
the  anterior  commissure  to  form  adventitious  cords.  9,  Direct  view,  recumbent 
patient;  web  postdiphtheric  (?)  or  congenital  (?).  "Rough  voice"  since  birth,  but 
larynx  never  examined  until  stenosed  after  di])htheria.  Web  removed  and  larynx 
eviscerated  with  punch  forceps;  recurrence  of  stenosis  (not  of  web).  Cure  by  laryngos- 
tomy. This  view  also  illustrates  the  true  depth  of  the  larynx  which  is  often  o\erlooked 
because  of  the  misleading  flatness  of  laryngeal  illustrations.  10,  Direct  laryngoscopic 
view;  postdiphtheric  hypertrophic  subglottic  stenosis.  Cured  by  gahanocauterization. 
II,  Direct  laryngoscopic  view;  postdiphtheric  hypertrophic  supraglottic  stenosis. 
Forceps  excision;  extubation  one  month  later;  still  well  after  four  years.  12,  Broncho- 
scopic  view  of  posttracheotomic  stenosis  following  a  "plastic  flap"  tracheotomy  done 
for  acute  edema.  13,  Direct  laryngoscopic  view;  anterolateral  thymic  compression 
stenosis  in  a  child  of  eighteen  months.  Cured  by  thymopexy.  14,  Indirect  larjiigo- 
scopic  (mirror)  view;  laryngostomy  rubber  tube  in  position  in  treatment  of  post- 
tyijhoid  stenosis.  15,  Direct  view;  posttyphoid  stenosis  after  cure  by  laryngostomy. 
Dotted  line  shows  place  of  excision  for  clearing  out  the  anterior  commissure  to  restore 
the  voice.  16,  Endoscopic  view  of  posttracheotomic  tracheal  stenosis  from  badly 
placed  incision  and  chondrial  necrosis.  Tracheotomy  originally  done  for  influenzal 
tracheitis.    Cured  by  tracheostomy. 


PLATE  V 


CHRONIC    STEXOSIS    OF    THE    LARYNX    AXD    TRACHEA  30I 

musculature,  has  been  successful  in  some  cases.  Repeated  removal 
and  replacement  of  the  intubation  tube  when  dyspnea  requires  it 
may  prove  sufficient  in  the  milder  cases.  Very  rarely  a  trache- 
otomy may  be  required;  if  so,  it  should  be  done  low.  The  wearing 
of  a  tracheotomic  cannula  permits  a  restoration  of  the  muscle 
balance  and  a  subsidence  of  the  subglottic  inflammation.  Cork- 
ing the  cannula  with  a  slotted  cork  (Fig.  iii)  will  now  restore 
laryngeal  breathing,  after  which  the  tracheotomic  cannula  may  be 
removed. 

Paralysis. — Bilateral  abductor  laryngeal  paralysis  causes 
severe  stenosis,  and  usually  tracheotomy  is  urgently  required.  In 
cadaveric  paralysis  both  cords  are  in  a  position  midway  between 
abduction  and  adduction,  and  their  margins  are  crescentic,  so  that 
sufficient  airway  remains.  Efforts  to  produce  the  cadaveric 
position  of  the  cords  by  division  or  excision  of  a  portion  of  the 
recurrent  laryngeal  nerves,  have  been  failures.  The  operation  of 
ventriculocordectomy  consists  in  removing  a  vocal  cord  and  the 
portion  or  all  of  the  ventricular  floor  by  means  of  a  punch  forceps 
introduced  through  the  direct  laryngoscope.  Usually  it  is  better 
to  remove  only  the  portion  of  the  floor  anterior  to  the  vocal  process 
of  the  arytenoid.  In  some  cases  monolateral  ventriculocordec- 
tomy is  sufficient;  in  most  cases,  however,  operation  on  both  sides 
is  needed.  An  interval  of  two  months  between  operations  is 
advisable  to  avoid  adhesions.  In  almost  all  cases,  ventriculo- 
cordectomy will  result  in  a  sufficient  increase  in  the  glottic  chink 
for  normal  respiration.  The  ultimate  vocal  results  are  good. 
Evisceration  of  the  larynx,  either  by  the  endoscopic  or  thyrotomic 
method,  usually  yields  excellent  results  when  no  lesion  other 
than  paralysis  exists.  Only  too  often,  however,  the  condition  is 
complicated  by  the  results  of  a  faultily  high  tracheotomy.  A 
rough,  inflexible  voice  is  ultimately  obtained  after  this  operation, 
especially   if   the   arytenoid    cartilage   is   unharmed.     In   recent 


302  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

bilateral  recurrent  paralysis,  it  may  be  worthy  of  trial  to  suture  the 
recurrent  to  the  pneumogastric.  Operations  on  the  larynx  for 
paralytic  stenosis  should  not  be  undertaken  earlier  than  twelve 
months  from  the  inception  of  the  condition,  this  time  being  allowed 
for  possible  nerve  regeneration,  the  patient  being  made  safe  and 
comfortable,  meanwhile,  by  a  low  tracheotomy. 

Ankylosis. — Fixation  of  the  crico-arytenoid  joints  with  an 
approximation  of  the  cords  may  require  evisceration  of  the  larynx. 
This,  however,  should  not  be  attempted  until  after  a  year's  lapse, 
and  should  be  preceded  by  attempts  to  improve  the  condition  by 
endoscopic  bouginage,  and  by  partial  corking  of  the  tracheotomic 
cannula. 

Neoplasms. — Decannulation  in  neoplastic  cases  depends  upon 
the  nature  of  the  growth,  and  its  curability.  Cicatricial  contrac- 
tion following  operative  removal  of  malignant  growths  is  best 
treated  by  intubational  dilatation,  provided  recurrence  has  been 
ruled  out.  The  stenosis  produced  by  benign  tumors  is  usually 
relieved  by  their  removal. 

Papillomata. — Decannulation  after  tracheotomy  done  for 
papillomata  should  be  deferred  at  least  6  months  after  the  dis- 
continuance of  recurrence.  Not  uncommonly  the  operative 
treatment  of  the  growths  has  been  so  mistakenly  radical  as  to 
result  in  cicatricial  or  ankylotic  stenoses  which  require  their 
appropriate  treatments.  It  is  the  author's  opinion  that  recurrent 
papillomata  constitute  a  benign  self-limited  disease  and  are  best 
treated  by  repeated  superficial  removals,  leaving  the  underlying 
normal  structures  uninjured.  This  method  will  yield  ultimately 
a  perfect  voice  and  will  avoid  the  unfortunate  complications  of 
cicatricial  hypertrophic  and  ankylotic  stenosis. 

Compression  Stenosis  of  the  Trachea. — Decannulation  in  these 
cases  can  only  follow  the  removal  of  the  compressive  mass,  which 
may    be    thymic,    neoplastic,    hypertrophic    or    inflammatory. 


1  JO  0 

■ '  \  1  n 


CHRONIC    STENOSIS    OF    THE    LARYNX   AND    TRACHEA  303 

Glandular  disease  may  be  of  the  Hodgkins'  type.  Thymic  com- 
pression yields  readily  to  radium  and  the  roentgenray,  and  the 
tuberculous  and  leukemic  adenitides  are  sometimes  favorably 
influenced  by  the  same  agents.  Surgery  will  relieve  the  compres- 
sion of  struma  and  benign  neoplasms,  and  may  be  indicated  in 
certain  neoplasms  of  malignant  origin.  The  possible  coexistence 
of  laryngeal  paralysis  with  tracheal  compression  is  frequently 
overlooked  by  the  surgeon.  Monolateral  or  bilateral  paralysis 
of  the  larynx  is  by  no  means  an  uncommon  postoperative  sequel 
to  thyroidectomy,  even  though  the  recurrent  nerves  have  been 
in  no  way  injured  at  operation.  Probably  a  localized  neuritis, 
a  cicatricial  traction,  or  inclusion  of  a  nerve  trunk  accounts  for 
most  of  these  cases. 

Hyperplastic  and  cicatricial  chronic  stenoses  preventing  decan- 
nulation  may  be  classified  etiologically  as  follows: 

1.  Tuberculosis 

2.  Lues 

3.  Scleroma 

4.  Acute  infectious  diseases 

(a)  Diphtheria 
{b)  Typhoid  fever 
(c)  Scarlet  fever 
{d)  Measles 
(e)  Pertussis 

5.  Decubitus 

(a)  Cannular 
{b)  Tubal 

6.  Trauma 

(a)  Tracheotomic 

ib)  Intubational 

(c)  Operative 

{d)  Suicidal  and  homicidal 

(<;)  Accidental  (by  foreign  bodies,  external  violence,  bullets,  etc.) 

Most  of  the  organic  stenoses,  other  than  the  paralytic  and 
neoplastic  forms,  are  the  result  of  inflammation,  often  with  ulcera- 
tion and  secondary  changes  in  the  cartilages  or  the  soft  tissues. 


304  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

Tuberculosis. — In  the  non-cicatricial  forms,  galvanocaustic 
puncture  applied  through  the  direct  laryngoscope  will  usually 
reduce  the  infiltrations  sufficiently  to  provide  a  free  airway. 
Should  the  pulmonary  and  laryngeal  tuberculosis  be  fortunately 
cured,  leaving,  however,  a  cicatricial  stenosis  of  the  larynx,  decan- 
nulation  may  be  accomplished  by  laryngostomy. 

Lues. — Active  and  persistent  antiluetic  medication  must  pre- 
cede and  accompany  any  local  treatment  of  luetic  laryngeal 
stenosis.  Prolonged  stretching  with  oversized  intubation  tubes 
following  excision  or  cauterization  may  sometimes  be  successful, 
but  laryngostomy  is  usually  required  to  combat  the  vicious  con- 
traction of  luetic  cicatrices. 

Scleroma  is  rarely  encountered  in  America.  Radiotherapy  has 
been  advocated  and  good  results  have  been  reported  from  the 
intravenous  injection  of  salvarsan.  Radium  may  be  tried,  and  its 
application  is  readily  made  through  the  direct  laryngoscope. 

Diphtheria. — Chronic  postdiphtheritic  stenosis  may  be  of  the 
panic,  spasmodic  or,  rarely,  the  paralytic  types;  but  more  often 
it  is  of  either  the  hypertrophic  or  cicatricial  forms.  Only  too 
frequently  the  stenosis  should  be  called  posttracheotomic  rather 
than  postdiphtheritic,  since  decannulation  after  the  subsidence  of 
the  acute  stenosis  would  have  been  easy  had  it  not  been  for  the 
sequelae  of  the  faulty  tracheotomy.  Prolonged  intubation  may 
induce  either  a  supraglottic  or  subglottic  tissue  hyperplasia. 
The  supraglottic  type  consists  in  an  edematous  thickening  around 
the  base  of  the  epiglottis,  sometimes  involving  also  the  glossoepi- 
glottic  folds  and  the  ventricular  bands.  An  improperly  shaped 
or  fitted  tube  is  the  usual  cause  of  this  condition,  and  a  change  to 
a  correct  form  of  intubation  tube  may  be  all  that  is  required. 
Excessive  polypoid  tissue  hypertrophy  should  be  excised.  The 
less  redundant  cases  subside  under  galvanocaustic  treatment, 
which  may  be  preceded  by  tracheotomy  and  extubation,  or  the 


CHRONIC    STENOSIS    OF    THE    LARYNX   AND    TRACHEA  305 

intubation  tube  may  be  replaced  after  the  application  of  the 
cautery.  The  former  method  is  preferable  since  the  patient  is 
far  safer  with  a  tracheotomic  cannula  and,  further,  the  constant 
irritation  of  the  intubation  tube  is  avoided.  Subglottic  hypertro- 
phic stenosis  consists  in  symmetrical  turbinal-like  swellings 
encroaching  on  the  lumen  from  either  side.  Cautious  galvano- 
cauterant  treatment  accurately  applied  by  the  direct  method 
will  practically  always  cure  this  condition.  Preliminary  trache- 
otomy is  required  in  those  cases  in  which  it  has  not  already  been 
done,  and  in  the  cases  in  which  a  high  tracheotomy  has  been  done, 
a  low  tracheotomy  must  be  the  first  step  in  the  cure.  Cicatricial 
types  of  postdiphtheritic  stenosis  may  be  seen  as  webs,  annular 
cicatrices  of  funnel  shape,  or  masses  of  fibrous  tissue  causing 
fixation  of  the  arytenoids  as  well  as  encroachment  on  the  glottic 
lumen.     (See  color  plates.) 

As  a  rule,  when  a  convalescent  diphtheritic  patient  cannot  be 
extubated  two  weeks  after  three  negative  cultures  have  been 
obtained  the  advisability  of  a  low  tracheotomy  should  be  con- 
sidered. If  a  convalescent  intubated  patient  cough  up  a  tube 
and  become  dyspneic  a  low  tracheotomy  is  usually  preferable  to 
forcing  in  an  oversized  intubation  tube. 

Typhoid  Fever. — Ulcerative  lesions  in  the  larynx  during  typhoid 
fever  are  almost  always  the  result  of  mixed  infection,  though 
thrombosis  of  a  small  vessel,  with  subsequent  necrosis  is  also 
seen.  If  the  ulceration  reaches  the  cartilage,  cicatricial  stenosis 
is  almost  certain  to  follow. 

Trauma. — The  chief  traumatic  factors  in  chronic  laryngeal 

stenosis  are :  (a)  prolonged  presence  of  a  foreign  body  in  the  larynx 

(b)  unskilled  attempts  at  intubation  and  the  wearing  of  poorly 

fitting  intubation  tubes;  (c)  a  faulty  tracheotomy;  (d)  a  badly 

fitting    cannula;    (e)    war   injuries;    (f)    attempted    suicide;    (g) 

attempted  homicide;  (h)  neglect  of  cleanliness  and  care  of  either 
20 


3o6 


BRONCHOSCOPY  AND  ESOPHAGOSCOPY 


intubation  tubes  or  tracheotomic  cannulae  allowing  incrustation 
and  roughening  which  traumatize  the  tissues  at  each  movement  of 
the  ever-moving  larynx  and  trachea. 

Treatment  of  Cicatricial  Stenosis. — A  careful  direct  endoscopic 
examination  is  essential  before  deciding  on  the  method  of  treat- 
ment for  each  particular  case.  Granulations  should  be  removed. 
Intubated  cases  are  usually  best  treated  by  tracheotomy  and  extu- 


FiG.  109. — Schema  showing  the  author's  method  of  laryngostomy.  The  hollow 
upward  metallic  branch  (N)  of  the  cannula  (C)  holds  the  rubber  tube  (R)  back  firmly 
against  the  spur  usually  found  on  the  back  wall  of  the  trachea.  Moreover,  the  air 
passing  up  through  the  rubber  tube  (R)  permits  the  patient  to  talk  in  a  loud  whisper, 
the  external  orifice  of  the  cannula  being  occluded  most  of  the  time  with  the  cork 
(K).  The  rubber  tubing,  when  large  sizes  are  reached  may  extend  down  to  the 
lower  end  of  the  cannula,  the  part  C  coming  out  through  a  large  hole  cut  in  the 
tubing  at  the  proper  distance  from  the  lower  end. 


bation  before  further  endoscopic  treatment  is  undertaken.  A 
certain  diagnosis  as  to  the  cause  of  the  condition  must  be  made  by 
laboratory  and  therapeutic  tests,  supplemented  by  biopsy  if 
necessary.  Vigorous  antiluetic  treatment,  especially  with  pro- 
tiodide  of  mercury,  must  precede  operation  in  all  luetic  cases. 
Necrotic  cartilage  is  best  treated  by  laryngostomy.  Intubational 
dilatation  will  succeed  in  some  cases. 

Laryngoscopic  bouginage  once  weekly  with  the  laryngeal  bougies 
(Fig.  42)  will  cure  most  cases  of  laryngeal  stenosis.  For  the 
trachea,  round,  silk- woven,  or  metallic  bougies  (Fig.  40)  are  better. 


CHRONIC    STENOSIS    OF    THE    LARYNX    AND    TRACHEA 


307 


Laryngostomy  consists  in  a  midline  division  of  the  laryngeal  and 
tracheal  cartilages  as  low  as  the  trache- 
otomic  fistula,  excision  of  thick  cicatricial 
tissue,  very  cautious  incision  of  the  scar 
tissue  on  the  posterior  wall,  if  necessary, 
and  the  placing  of  the  author's  laryngos- 
tomy tube  for  dilatation  (Fig.  109).  Over 
the  upward  branch  of  the  laryngostomy 
tube  is  slipped  a  piece  of  rubber  tubing 
which  is  in  turn  anchored  to  the  tape 
carrier  by  braided  silk  thread.  Progres- 
sively larger  sizes  of  rubber  tubing  are 
used  as  the  laryngeal  lumen  increases  in 
size  under  the  absorptive  influence  of  the 
continuous  elastic  pressure  of  the  rubber. 
Several  months  of  wearing  the  tube  are 
required  until  dilatation  and  epithelializa- 
tion  of  the  open  trough  thus  formed  are 
completed.  Painstaking  after-care  is 
essential  to  success.  When  dilatation  and 
healing  have  taken  place,  the  laryngos- 
tomy wound  in  the  neck  is  closed  by  a 
plastic  operation  to  convert  the  trough 
into  a  trachea  by  supplying  an  anterior 
wall. 

Intuhalional  treatment  of  chronic  laryn- 
geal stenosis  may  be  tried  in  certain  forms 
of  stenosis  in  which  the  cicatrices  do  not 
seem  very  thick.  The  tube  is  a  silver- 
plated  brass  one  of  large  size  (Fig.  no). 
A  post  which  screws  into  the  anterior 
surface  of  the  tube  prevents  its  expulsion. 


Fig.  110. — The  author's 
retaining  intubation  tube 
for  treatment  of  chronic 
laryngeal  stenosis.  The 
tube  (A)  is  introduced 
through  the  mouth,  then 
the  post  (B)  is  screwed  in 
through  the  tracheal 
wound.  Then  the  block 
(C)  is  slid  into  the  wound, 
the  square  hole  in  the  block 
guarding  the  post  against 
all  possibility  of  unscrew- 
ing. If  the  threads  of  the 
post  are  properly  fitted 
and  tightly  screwed  up 
with  a  hemostat,  however, 
there  is  no  chance  of 
unscrewing  and  gauze 
packing  is  used  instead  of 
the  block  to  maintain  a 
large  fistula.  The  shape 
of  the  intubation  tube  has 
been  arrived  at  after  long 
clinical  study  and  trials, 
and  cannot  be  altered 
without  risk  of  falling  into 
errors  that  have  been  made 
and  eliminated  in  the 
development  of  this  shape. 


3o8  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

Over  the  post  is  slipped  a  block  which  serves  to  keep  open  the 
tracheal  fistula.  Detailed  discussion  of  these  operative  treat- 
ments is  outside  the  scope  of  this  work,  but  mention  is  made  for 
the  sake  of  completeness.  Before  undertaking  any  of  the  fore- 
going procedures,  a  careful  study  of  the  complete  descriptions 
in  Peroral  Endoscopy  is  necessary,  and  a  practical  course  of 
training  is  advisable. 


CHAPTER  XXXIX 
DECANNULATION  AFTER  CURE  OF  LARYNGEAL  STENOSIS 

In  order  to  train  the  patient  to  breathe  again  through  the 
larynx  it  is  necessary  to  occlude  the  cannula.  This  is  best  done 
by  inserting  a  rubber  cork  in  the  inner  cannula.  At  first  it  may 
be  necessary  to  make  a  slot  in  the  cork  so  as  to  permit  some  air 
to  enter  through  the  tube  to  supplement  the  insufficient  supply 


A  B  C  D  it 

Fig.  Ill . — Illustration  of  corks  used  to  occlude  the  cannula  in  training  patients 
to  breathe  through  the  mouth  again,  before  decannulation.  The  corks  allow  air 
leakage,  the  amount  of  which  is  regulated  by  the  use  of  different  shapes.  A  smaller 
and  still  smaller  air  leak  is  permitted  until  finally  an  ungrooved  cork  is  tolerated.  A 
central  hole  is  sometimes  used  instead  of  a  slot.  A,  one-third  cork;  B,  half  cork; 
C,  three-quarter  cork;  D,  whole  cork. 

obtainable  through  the  insufficiently  patulous  glottis,  new  corks 
with  smaller  grooves  being  substituted  as  laryngeal  breathing 
becomes  easier.  Corking  the  cannula  is  an  excellent  orthopedic 
treatment  in  certain  cases  where  muscle  atrophy  and  partial 
inflammatory  fixation  of  the  cricoarytenoid  joints  are  etiological 
factors  in  the  stenosis.  The  added  pull  of  the  posterior  crico- 
arytenoid muscles  during  the  slight  effort  at  inspiration  restores 
their  tone  and  increases  the  mobility  of  all  the  attached  structures. 
By  no  other  method  can  panic  and  spasmodic  stenosis  be  so 
efficiently  cured. 

Following  the  subsidence  of  an  acute  laryngeal  stenosis,  it  is 

309 


3IO 


BRONCHOSCOPY  AND  ESOPHAGOSCOPY 


my  rule  to  decannulate  after  the  patient  has  been  able  to  breathe 
through  the  larynx  with  the  cannula  tightly  corked  for  3  days  and 
nights.  This  rule  does  not  apply  to  chronic  laryngeal  stenosis, 
for  while  the  lumen  under  ordinary  conditions  might  be  ample,  a 
slight  degree  of  inflammation  might  render  it  dangerously  small. 
In  these  cases,  many  weeks  are  sometimes  required  to  determine 


u 


GRINDING 
TAPER 


GRINDING 
GROOVE 


Fig.  XI 2. — This  illustration  shows  the  method  of  making  safe  corks  for  trache- 
otomic  cannulae  by  grinding  pure  rubber  cord  to  shape  on  an  emery  wheel. 
After  grinding  the  taper,  if  a  partial  cork  is  desired,  a  groove  is  ground  on  the 
angle  of  the  wheel.  If  a  half-cork  is  desired  half  of  the  cork  is  ground  away  on 
the  side  of  the  wheel.  Reliable  corks  made  in  this  way  are  now  obtainable  from 
Messers  Charles  J.  Pilling  and  Son. 

when  decannulation  is  safe.  A  test  period  of  a  few  months  is 
advisable  in  most  cases  of  chronic  laryngeal  stenosis.  Recurrent 
contractions  after  closure  of  the  wound  are  best  treated  by  endo- 
scopic bouginage.  The  corks  are  best  made  of  pure  rubber  cord, 
cut  and  ground  to  shape,  and  grooved,  if  desired,  on  a  small  emery 
wheel  (Fig.  112).  The  ordinary  rubber  corks  and  those  made  of 
cork-bark  should  not  be  used  because  of  their  friability,  and  the 
possible  aspiration  of  a  fragment  into  the  bronchus,  where  rubber 
particles  form  very  irritant  foreign  bodies. 


BIBLIOGRAPHY 

The  following  list  of  publications  of  the  author  may  be  useful 
for  reference: 

1.  Peroral   Endoscopy   and  Laryngeal  Surgery,   Textbook,  1914.     (Contains  full 

bibliography  to  date  of  publication.) 

2.  Acromegaly  of  the  Larynx.     Journ.  Amer.  ^Sled.  .\sso.,  Xov.  30,   1918,  Vol. 

LXXI,  pp.  1 787-1 789. 

3.  A  Fence  Staple  in  the  Lung.     A  Xew  Method  of  Bronchoscopic   Removal. 

Journ.  Amer.  Med.  Asso.,  Vol.  LXIV,  June  5,  1917,  pp.  1906-7. 

4.  Amalgam  Tooth-filling  Aspirated  into  Lung  During  Extraction.     Dental  Cos- 

mos, Vol.  LIX,  May,  191 7,  pp.  500-502. 

5.  .\malgam  Filling  Removed  from  Lung  after  a  Seven  Months'  Sojourn:  Case 

Report.     Dental  Cosmos,  April,  1920. 

6.  A  Mechanical   Spoon   for   Esophagoscopic  Use.     The  Laryngoscope,  January, 

1918,  pp.  47-48. 

7.  An  Anterior  Commissure  Laryngoscope.     The  Laryngoscope,  \'ol.  XXV,  .\ug., 

1915,  p.  589. 

8.  Ancient   Foreign    Body    Cases.     Editorial.     The  Laryngoscope,  Vol.  XXVII, 

July,  1917,  pp.  583-584. 

9.  An  Esophagoscopic  Forceps.     The  Laryngoscope,  Jan.,  1918,  p.  49. 

10.  A  X^ew  Diagnostic  Sign  of  Foreign  Body  in  Trachea  or  Bronchi,  the  "Asthma^ 

toid  Wheeze."     Amer.  Journ.  Med.  Sciences,  Vol.  CLVI,  X^o.  5,  Xov.,  1918, 
p.  625. 

11.  A  Xew  Method  of  Working  Out  Difficult  Mechanical  Problems  of  Bronchoscopic 

Foreign-body  Extraction.     The  Laryngoscope,  Vol.  XXVII,  Oct.,  191 7,  p. 

725- 

12.  Arachidic  Bronchitis.     Journ.  Amer.  Med.  Asso.,  .\ug.  30,  1919,  Vol.  LXXIII, 

pp.  672-677. 

13.  Band  of  a  Gold  Crown  in  the  Bronchus:  Report  of  a  Case.     Dental  Cosmos. 

Vol.  LX,  Oct.,  1918,  p.  905. 

14.  Bronchiectasis  and  Bronchiectatic  Symptoms  Due  to  Foreign  Bodies.     Penn. 

Med.  Journ.,  Vol.  XIX,  Aug.,  1916,  pp.  807-814. 

15.  Bronchoscopic  and  Esophagoscopic  Postulates.     Annals  of  Otology,  Rhinology 

and  Laryngology,  June,  1916,  pp.  414-416. 

16.  Bronchoscopic  Removal  of  a  Collar  Button  after  Twentj'-six  Years  Sojourn  in 

the  Lung.     Annals  of  Otology,  Rhinology  and  Laryngology,  June,  1913. 

17.  Bronchoscop3\     Keen's  Surgery,  1921,  Vol.  VIII. 

18.  Caisson   Bronchoscopy  in  Lung-abscess  Due  to  Foreign  Body.     Surg.,  Gyn. 

and  Obstet.,  Oct.,  191 7,  pp-  424-428. 

19.  Cancer  of  the  Larynx.     Is  it  Preceded  by  a  Recognizable  Precancerous  Condi- 
tion?    Proceedings  Amer.  Laryngol.  Soc,  1922. 

20.  Din.  Editorial.     The  Laryngoscope,  Vol.  XXVI,  Dec,  1916,  pp.  1385-1387. 

311 


312  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

21.  Direct  Laryngoscopy  and  Bronchoscopy.     Binnie's  Regional  Surgery.     Vol.  I, 

Sec.  XVIII,  pp.  401-473. 

22.  Drug  Armamentarium  of  the  Endoscopist.     Therapeutic  Gazette,  April  15, 

1921. 

23.  Endoscopic    Perorale    et    Chirurgie    Laryngienne.     Arch,    de    Laryngol.,    T. 

XXXVII,  No.  3,  1914,  pp.  649-680. 

24.  Endoscopy   and   the  War.     Editorial.     The  Laryngoscope,  Vol.  XXVI,  June, 

1916,  p.  992. 

25.  Endothelioma  of   the   Right  Bronchus  Removed  by  Peroral   Bronchoscopy. 

Amer.  Journ.  of  Med.  Sci.,  No.  3,  Vol.  CLII,  March,  191 7,  p.  371. 

26.  Esophageal   Stenosis   Following   the   Swallowing  of   Caustic   Alkalies,   Journ. 

Amer.  Med.  Asso.,  July  2,  1921,  Vol.  LXXVII,  pp.  22-23. 

27.  Esophagoscopic  Radium  Screens.     The  Laryngoscope,  Feb.,  1914. 

28.  Foreign   Bodies  in   the  Insane.     Editorial.     The  Laryngoscope,  Vol.  XXVII, 

June,  1917,  pp.  513-515- 

29.  Foreign  Bodies  in  the  Larynx,  Trachea,  Bronchi  and  Esophagus  Etiologically 

Considered.     Trans.  Sec.  Laryn.,  Otol.  and  Rhin.,  Amer.  Med.  Asso.,  191 7,  pp. 
36-56. 

30.  Gold  Three-tooth  Molar  Bridge  Removal  from  the  Right  Bronchus:  Case 

Report.     Dental  Cosmos,  Oct.,  1919. 

31.  High  Tracheotomy  and  Other  Errors  the  Chief  Causes  of  Chronic  Laryngeal 

Stenosis.     Surg.,  Gyn.  and  Obstet.,  May,  1921,  pp.  392-398. 

32.  Inducing  a  Child  to  Open  Its  Mouth.     Editorial.     The  Laryngoscope,  Vol. 

XXVI,  Nov.,  191 7,  p.  795. 

33.  Intestinal  Foreign  Bodies.     Editorial*     The  Laryngoscope,  Vol.  XXVI,  May, 

1916,  p.  929. 

34.  Laryngoscopic,     Esophagoscopic     and     Bronchoscopic     Clinic.     International 

Clinics,  Vol.  IV,  1918.     J.  B.  Lippincott  Co. 

35.  Local   Application  of  Radium   Supplemented  by  Roentgen  Therapy  (Discus- 

sion).    Amer.  Journ.  of  Roentgenology. 

36.  Localization  of  the  Lobes  of  the  Lungs  by  Means  of  Transparent  Outline  Films. 

Amer.  Journ.  Roent.,  Vol.  V,  Oct.,  1918,  p.  456.     Also  Proc.  Amer.  Laryn., 
Rhin.  and  Otol.  Soc,  1918. 

37.  Mechanical   Problems   of   Bronchoscopic   and   Esophagoscopic   Foreign  Body 

Extraction,  Journ.  Am.  Med.  Assn.,  Jan.  27,  191 7. 

38.  Observation  on  the  Pathology  of  Foreign  Bodies  in  the  Air  and  Food  Passages 

Based  on  the  Analysis  of  628  Cases.     Mutter  Lecture,  191 7,  Surg.    Gyn. 
and  Obstet.,  Mar.,  1919,  pp.  201-261. 

39.  Orthopedic  Treatment  by  Corking.     Journ.  of  Laryn.  and  Otol.,  London,  Vol. 

XXXII,  Feb.,  191 7. 

40.  Peroral  Endoscopy.     Journ.  of  Laryn.  and  Otol.,  Edinburgh,  Nov.,  1921. 

41.  Peroral  Endoscopy  and  Laryngeal  Surgery.     The  Laryngoscope,  Feb.,  1919. 

42.  Postulates  on  the  Cough  Reflex  in  Some  of  its  Medical  and  Surgical  Phases. 

Therapeutic  Gazette,  Sept.  15,  1920. 

43.  Prognosis  of  Foreign  Body  in  the  Lung.     Journ.,  Amer.  Med.  Asso.,  Oct.  8,  1921, 

Vol.  LXXVII,  pp.  1 1 78-1 181. 

44.  Pulsion  Diverticulum  of  the  Esophagus.     Surg.,  Gyn.  and  Obstet.,  Vol.  XXI, 

July,  1915,  pp.  52-55. 


BIBLIOGRAPHY  313 

45.  Radium.     Editorial.     The  Lan-nj^'oscope,   Vol.  XXVI,  .Vug.,  1916,  pp.  iiii- 

1113. 

46.  Reaction  after  Bronchoscopy.     Penn.  Med.  Journ.,  April,  1919.     Vol.  XXII 

P-  434- 

47.  Root-canal  Broach  Removed  from  the  Lung  by  Bronchoscopy.     The  Dental 

Cosmos,  Vol.  LVII,  March,  191 5,  p.  247. 

48.  Safety  Pins  in  Stomach,  Peroral  Gastroscopic  Removal  without  Anesthesia. 

Journ.  Amer.  Med.  Asso.,  Feb.  26,  1921,  Vol.  LXXVI,  pp.  577-579. 

49.  Symptomatology  and  Diagnosis  of  Foreign  Bodies  in  the  Air  and  Food  Passages. 

Am.  Journ.  Med.  Sci.,  May,  1921,  Vol.  CLXI,  No.  5,  p.  625. 

50.  The  Bronchial  Tree,  Its  Study  by  Insufflation  of  Opaque  Substances  in  the 

Living.     Amer.    Journ.    Roentgenology,  Vol.   5,  Oct.,   1918,   p.  454.     Also 
Proc.  Amer.  Laryn.,  Rhinol.  and  Otol.  Soc,  1918. 

51.  Thymic   Death.     Editorial.     The  Laryngoscope,  Vol.   XXVI,  May,  191 6,  p. 

929. 

52.  Tracheobronchitis  Due  fo  Nitric  Acid  Fumes.     New  York  Med.  Journ.,  Nov. 

4,  1916,  pp.  898-899. 

53.  Treatment  of  Laryngeal  Stenosis  by  Corking  the  Tracheotomic  Cannula,  The 

Laryngoscope,  Jan.,  191 9. 

54.  Vcntriculocordectomy.     Proceedings  Amer.  Laryngol.  Soc,  1921. 

55.  New  Mechanical  Problems  in  the  Bronchoscopic  E.xtraction  of  Foreign  Bodies 

from  the  Lungs  and  Esophagus.     Annals  of  Surgery,  Jan.,  1922. 

56.  The    Diaphragmatic    Pinchcock    in    So-called    Cardiospasm.     Laryngoscope, 

Jan.,  1922. 


INDEX 


Aberrant  thyroid  tumors  in  larynx,  202 
Abscess  of  larynx,  221 
of  lung,  227 
chronic,  228 
drainage  of,  drainage  bronchoscope 

for,  ig 
of  lung-mapping  in,  229 
post-tonsillectomy,     medicament    in, 

228 
retropharyngeal,  draining  of,  aspirat- 
ing tube  for,  28 
Acromegalic  stenosis  of  larynx,  tracheot- 
omy for,  280 
Actinomycosis  of  esophagus,  272 
Adenoma  in  larynx,  201 
Adhesions,  liberation  of,  for   formation 

of  adventitious  vocal  cords,  94 
Adolescent's  size  bronchoscope,  20,  21 
Adults,  anesthesia  for,  in  peroral  endos- 
copy, 66 
direct  laryngoscopy  in,  83 
laryngeal  growths  in  larynx  of,  differ- 
ential diagnosis  of,  211 
papilloma  of  larynx  in,  205 
size  bronchoscope,  20,  21 
esophageal  speculum,  23 
esophagoscope,  22,  23 
laryngoscope,  18 
After-care  of  endolaryngeal  operations, 

96 
Air  insufflation,  rubber  diaphragm  with 
perforaton  for  forceps  for  esophagos- 
cope for,  24,  25 
passages,     foreign     bodies     in,     126. 
See    also    Foreign    bodies    in    air 
passages. 
Alcohol  for  sterilization  of  instruments, 

49,  51 

Alligator  forceps,  32,  33 

Amputation  of  epiglottis  for  palliation 
of  odynphagia  or  dysphagia  in  tuber- 
culous or  malignant  disease,  93 


Amyl  nitrite  and  oxygen  for  bronchos- 
copic   oxygen   insufflation,    72 
for  respiratory  arrest,  48 
Amyloid  tumors  of  larynx,  202 
Anchoring   foreign   body   against   tube 

mouth,  method  of,  163 
Anesthesia  by  intratracheal  insufflation 
in  paralysis  of  larynx,  68 
direct  laryngoscopy  in  children  with- 
out, reasons  for,  90 
endotracheal,    for    administration    of 

ether,  advantages  of,  68 
ether,   for  ballooning  esophagoscopy, 

114 
for  esophagoscopic  removal  of  foreign 

bodies,  190 
for  peroral  endoscopy,  65 
for  adults,  66 
for  children,  65 
general,  65 

technic,  67 
local,  67 
for    removal    of    foreign    body    from 

larynx,  157 
for  tracheotomy,  283 
general,  examination  of  patient  with 
throat  mirror  before,  68 
for  extraction  of  very  large  bodies 
from  esophagus,  194 
in  bronchoscopy,  67 
in  diagnosis  of  cricopharyngeal  spas- 
modic stenosis  of  esophagus,  246 
in  direct  laryngoscopy  in  children,  67 

in  diseases  of  larynx,  221 
in  gastroscopy,  273 
insufflation,  insertion  of  catheter  for, 
rules  for,  69 
with  Elsberg  apparatus,  97 
Anesthesin    for    painful    swallowing    in 

foreign  body  in  esophagus,  185 
Anesthetics,    insufflation    of,    broncho- 
scope for,  19 
IS 


3i6 


INDEX 


Anesthetizing  a  tracheotomized  patient, 

68 
Angioma  of  esophagus,  271 

of  larynx,  202 
Angioneurotic  edema,  233 

involving  esophagus,  272 
Angle  of  esophagoscope  in  facilitating 

introduction  of,  24 
Animal     objects,     removal     of,     from 

tracheobronchial  tree,  174 
Ankylosis  of  cricoarytenoid  joints,  302 
Annular   edema    above    tightly    fitting 

foreign  body,  172 
Anomalies  of  tracheobronchial  tree,  225 
Anterior  commissure  laryngoscope,  18, 

19 
as  pleuroscope,  19,  26 
portion  of  larynx  removal  of  growths 
in,  91 
Antiperistalsis,  esophageal,  250 
Antispasmodic,    atropin    and    morphin 

for,  in  bronchoscopy,  65 
Antitoxin,  diphtheria,  in  doubtful  cases 
of  diphtheria,  226 
in  laryngeal  diphtheria  simulating 

foreign  body,  156 
in  tracheobronchial  diphtheria,  227 
Aortic  narrowing  of  esophagus,  60 
Aphagia,  184 
Aphonia    due    to    cicatricial    webs    of 

larynx,  223 
Aphorisms,  125 

Apparatus  for  insufflation  of  ether  or 
chloroform  during  bronchoscopy,  29 
Aquiring  skill  in  endoscopy,  117 
Arrowsmith's  safety-pin  closer,  42,  170, 

192,  45 
Artificial  respiration,  197,  283,  289 
Arytenoid  cartilages,  anatomy,  52 
Asepsis  in  endoscopic  procedures,  47,  48 

in  operating  room,  47,  48 
Asphyxia   from   pressure   in   extraction 
of  foreign  body  from  esophagus,  197 
Aspirating  bronchoscope,  20 
tubes,  27 
endoscopic,  protected-aperture,  28 
malleable  tracheotomic,  Jackson's, 
28 


Aspiration,  bronchial,  in  tracheotomy, 

290 
Aspirator,  mechanical  Robinson's,  29 

portable  for  endoscopy,  29 
Aspirators,  28 

electric,  28 

hand,  28 
Asthma,  bronchial,  230 
Asthmatoid    wheeze     as    confirmatory 

sign  of  bronchial  foreign  body,  136 
Atresia  of  esophagus,  absolute,  salivary 

drainage  in,  259 
Atrophic  tracheitis,  233 
Atropin  added  to  morphin  in  bronchos- 
copy for  foreign  bodies,  65 
Audible  slap,  134,  145 
Auer  and  Meltzer,  29 
Auerbach  and  Meissner  plexus,  245 
Autodrownage,  154,  230 

Ball  forceps,  Jackson's,  172 
Ballooning  esophagoscopy,  114 

esophagus  with  air,  window  plug  for 

esophagoscope  in,  24,  25 
gastroscopy,  lens-system,  275 
stomach  in  gastroscopy,  274 
Bandage  gauze  for  endoscopic  sponges,  3 1 
Bands,  ventricular,  53 
Basket  punch  forceps,  large,  38 
Batteries  for  endoscopy,  26 
Battery,  dry  cells  of,  renewal  of,  51 
endoscopic,  sterilization  of,  27 
Jackson's  endoscopic,  27 
pocket,  not  dependable,  27 
Benign  growths  in  larynx,  201 

adult,     operative     removal     of, 

tubular  laryngoscope  for,  19 
removal  of,  91 
in  tracheobronchial  tree,  bronchos- 
copic  removal  of,  207 
symptoms  of,  207 
primary  in   tracheobronchial   tree, 

207 
repeated  removal  of,  for  prophylac- 
tic of  cancer,  206 
neoplasms  of  esophagus,  209 
tumors,  large,  above  cords,  removal 
of,  93 


INDEX 


317 


Bite  block  to  prevent  closure  of  jaws  on 

endoscopic    tube,    32 
Blood   and   secretions,   removal   of,   by 
aspirator,     during     direct    laryngos- 
copy, 87,  91 
Block,  bite,  to  prevent  closure  of  jaws  on 

endoscopic  tube,  2,2 
Bolus   of   meat,    mechanical   spoon    for 
removal  of,  42,  45 
removal  of,  from  esophagus,  196 
Bones,     esophagoscopic     removal     of, 

rotation  forceps  for,  34 
Bougie,  laryngeal,  Jackson's,  46 

metallic,    for    cicatricial    stenoses    of 
larynx,  43,  46 
of  trachea,  42,  46 
retrograde   esophageal,   Jackson   and 
Tucker's,  41 
Bougies,  endoscopic,  Jackson's,  46 
esophagoscopic,  large,  esophagoscopes 
for  admitting,  22,  24 
Bouginage,  blind,  perforation  by,  mech- 
anism of,  in  cicatricial  stenosis  of 
esophagus,  253 
esophagoscopic,  in  cicatricial  stenosis 

of  esophagus,  256 
of  malignant  esophagus,   219 
thermic,     in    cicatricial     stenosis    of 
esophagus,  257 
Bowen,  142,  240 

Boyce  position  for  bronchoscopy,  77 
for  esophagoscopy,  46,  77 
sign  in  diagnosis  of  diverticulum  of 

esophagus,  263 
thimble,  McKee-McCready  modifica- 
tion of,  32 
Brenneman's  method  for  impermeable 
strictures    in    cicatricial     stenosis    of 
esophagus,  258 
Bronchi  or  bronchus: 
anatomy,  54 

bronchoscopy  in  diseases  of,  224 
compression  stenosis  of,  225 

treatment,  226 
corks  in,  extraction  of,  172 
dimensions  of,  56 
examination  of,  102 


Bronchi  or  bronchus,  expiratory  valve- 
like     obstruction     of,     roentgeno- 
graphic  signs  of,  138 
foreign  body  in,  asthmatoid  wheeze  in, 
136 
for  prolonged  periods,  177 

bronchoscopy  for  diagnosis, 

177,  179 
gravity  of,  178 
pathology,  178 
prognosis,  179 
symptoms,  129 
time  of  aspiration,  177 
treatment,  179 
tubercular  symptoms  in,  177 
in  upper  lobe,  forceps  for,  37 

removal  of,  174 
irritating,  such  as  peanut  kernel, 

early  symptoms,  129 
physical  signs,  134 

in    complete    bronchial    ob- 
struction, 135 
in  expiratory  valve-like  ob- 
struction, 135 
in  partial  bronchial  obstruc- 
tion, 136 
prolonged  obstruction  in,  137 
symptoms,  128 

tightly  fitting,  extraction  of,  172 
marbles  in,  extraction  of,  172 
normal  mov^ements  of,  57 
obstruction  of,  complete,  roentgeno- 

graphic  signs  in,  139 
pebbles  in,  extraction  of,  172 
removal  of  open  safety  pins  from,  169 
right,    upper-lobe,    recognizing,    104 
safety    pin    in,    upper-lobe-bronchus 

forceps  for,  35 
upper-lobe,     coil-spring     hook     for, 
Jackson's,  44 
problem    with    mushroom    anchor 
problem,    Jackson's    method    of 
solution,  169 
Bronchial  aspiration  in  tracheotomy,  290 
asthma,  230 
dilators,  Jackson's,  37,  40 

self-expanding,    Jackson's,    37,    42 
mapping,  Jackson's  method,  141,  142 


3i8 


INDEX 


Bronchial  mucosa,  color  of,  224 
narrowing  of  esophagus,  60 
secretions,    removal    of,    by    sponge- 
pumping,  31 
stenosis,  229 
symptoms    in    foreign    body    cases, 

145 
Bronchiectasis,  229 

lavage  treatment  of,  drainage  bron- 
choscope for,  19 
Bronchoscope,  19 

adolescent's  size,  20,  21 
adult's  size,  20,  21 
aspirating,  20 
child's  size,  20,  21 
correct  holding  of,  102 
difficulties  in  introduction  of,  100 
drainage,  19,  20 
when  used,  21 
entering  anteriorly  branching  middle 
lobe  bronchus,  104 
bronchi,  103 

left  upper-lobe  bronchus,  105 
middle-lobe  bronchus,    105 
right  upper-lobe  bronchus,  105 
importance  of  size,  position  and  shape 

of  drainage  outlets  on,  21 
incorrect  holding  of,  102 
infant's  size,  20,  21 
introduction  of,  97,  100,  loi 

through  glottis,  98 
Jackson's,  20 

lip    of,    in    disimpaction    of    foreign 
bodies,  172 
valuable   aid  in  solution  of  foreign 
body  problems,  160 
passage  down  trachea,  rules  for,  103 
special  sizes,  21 
thread  practice  with,  119 
Bronchoscopic  appearances  in    disease, 
224 
aspiration,     Robinson's      mechanical 

aspirator  for,  29 
finding  of  foreign  body,  152 
grasping  forceps,  ^^ 
lever,  fulcrum  of,  position  of,  103 
mechanical  spoon,  Jackson's,  42,  45 
oxygen  insufflation,  71 


Bronchoscopic  oxygen  insufflation, 
dangers  in,  71 
indications  for,  71 
removal   of   benign   growths   in    tra- 
cheobronchial tree,  207 
sponges,  method  of  making,  32 

sterilization  of,  32 
table,  Jackson's,  46 
tamponade,    Jackson's    tampon    for, 

232 
views,  55 
Bronchoscopy,   after-effects,   153 

and   laryngeal   operation,    anesthetic 

technic  in,  66 
anesthesia  in,  67 

aspiration     of    endotracheobronchial 
secretions  at,  aspirating  tube  for,  28 
Boyce  position  for,  77 
complications,  153 
contraindications  for,  151 
correct  position  of  cervical  spine  for,  74 
drowning  of  patient  in  his  own  secre- 
tions, 154 
dyspnea  following,  causes  of,  154 
fatigue  in  children  after,  154 
fluoroscopic,  176 

for  foreign  bodies,  morphin  and  atro- 
pin  for,  65 
best  time  for,  152 
unsuccessful,  181 
for  suspected  foreign  bodies,  indica- 
tions for,  151 
in  diseases,  contraindications  for,  224 
indications  for,  224 
of  trachea  and  bronchi,  224 
in  malignant  growths  of  trachea,  214 
in  older  children,   morphin  sulphate 

preceding,  65 
insufflation    of    ether   or    chloroform 

during,  apparatus  for,  29 
local  anesthesia  in,  97 
morbidity  of,  151 
mortality  of,  151 
oral,  schemia  iUustrating,  99 
position  for,  76 

of  patient  for,  46 
reaction  following,  general,  153 
local,  154 


INDEX 


319 


Bronchoscopy,   subglottic  edema   after, 
154 
treatment,  155 
supraglottic  edema  following,  154 
surgical  shock  after,  154 
technic  of,  97 
temperature  after,  153 
Bronchotomy,  internal,  180 

Cadaver  practice,  1 20 
Cadaveric   dimensions    of   tracheobron- 
chial tree,  56 
Canal,  obstruction  of  during  esophagos- 

copy,  23 
Cancer    of    esophagus,    216.     See    also 
Malignant  disease  of  esophagus. 
of  larynx,  papilloma  of  larynx  and, 
differentiation,  204, 
taking  specimen  for  diagnosis,  92. 
prophylactic   of,   removal   of    benign 
growths  in  larynx  for,  206 
Cannula;,  tracheotomic,  281 

corks  for,  method  of  making,  310 
endoscopic    removal    of,    expansile 

forceps  for,  36 
Jackson's,  282 
Caps,  endoscopic  removal  of,  expansile 

forceps  for,  36 
Carcinomatous  ulcer  of  esophagus,  241 
Cardiospasm,  247,  250 

site  of,  62 
Carina,  55 

indentification  of,  103 
Carrier,  sponge,  30 
Cartilage,  arytenoid,  anatomy,  52 

cricoid,  anatomy,  52 
Cartridge  shells,  endoscopic  removal  of, 

expansile  forceps  for,  36 
Catheter,   insertion  of,   for  insufflation 

anesthesia,  rules  for,  69 
Cauterization     for    chronic     subglottic 

edema,  221 
Cauterizations,      deep,      perichondritis 

from,  95 
Cautery  electrode,  flat  blade,  Jackson's, 

41 
pointed,  41 
handle,  41 


Cervical  eso{)hagus,  rupture  of,  239 
spine,  correct  position  of,  for  esopha- 
goscopy  and  bronchoscopy,  74 
curved   position   of,    with   anterior 
convexity  in  Rose  position,  75 
Charters-Symonds    esophageal     intuba- 
tion tube,  219 
Child,  inducing  to  open  mouth,  Jack- 
son's method,  90 
Child's  mouth,  gums,  and  lips,  wound- 
ing of,  90 
size  bronchoscope,  20,  21 
esophageal  speculum,  23 
esophagoscope,  22,  23 
laryngoscope,  18 
Children,   anesthesia  for,  in   bronchos- 
copic  clinic,  65 
cocain  in,  65,  90,  284 
direct  laryngoscopy  in,  89 
anesthesia  in,  67 

without  anesthesia,  reasons  for, 
90 
dyspnea  in,  from  large  esophagoscope, 

24 
older,    morphin    sulphate    preceding 

bronchoscopy  in,  65 
papilloma  of  larynx  in,  203 
dyspnea  in,  205 

endolaryngeal  extirpation  of,  204 
methods  of  treatment,  203 
radical  removal  of,  205 
repeated  superficial  removal  in, 
204 
Chlorine  poisoning,  bronchial  aspiration 
and  bronchoscopic  oxygen  insufflation 
in,  291 
Chloroform  in  esophagoscopy,  67 
in  gastroscopy,  67 

insufflation  of,  during  bronchoscope^, 
apparatus  for,  29 
Cicatricial     and     hyperplastic    chronic 
stenoses  preventing  decannulation, 

303 
stenosis  of  esophagus,  251 

dilatation     of,     by     endoscopic 
method,  43 
of  larynx,  endoscopic  evisceration  of 
larynx  for,  94 


320 


INDEX 


Cicatricial  stenosis  of  larynx,  metallic 
bougie  for,  43,  46 
treatment,  306 
of    trachea,    metallic    bougies    for, 
42,  46 
Closure,  endoscopic,  of  open  safety-pin 
lodged    point    upward,    Jackson's 
method,  42,  44 
of  larynx,  mechanism  of,  52 
Cocain,  65,  90,  284 

contraindicated,  morphin  used,  67 
in  children,  90 
poisoning,  197 
Coil-spring    hook   for   upper-lobe-bron- 
chus, Jackson's,  44 
Coin,  hiding  of,  by  folding  downward 

of  plica  cricopharyngeus,  189 
Color  of  bronchial  mucosa,  224 
Commercial   current,    danger   from,   26 
lye  preparations,  dangers  in  use  of,  251 
Commissure,     anterior,     laryngoscope, 

18,  19 
Complications  after  endolaryngeal  op- 
erations, 96 
during  endolaryngeal  operations,  96 
Compression  stenosis,  of  bronchi,  endo- 
scopic picture  of,  225 
treatment,  226 
of  esophagus,  243 
appearances  in,  243 
lesions  associated  with,  243 
simulating  spasmodic  stenosis,  249 
treatment,  243 
of  trachea,  302 
and  bronchi,  225 
treatment,  225 
Conducting     cords,     rubber      covered, 

sterilization  of,  49 
Congenital  esophagotracheal  fistula,  237 
laryngeal  stridor,  222 

treatment,  223 
stricture  of  esophagus,  237 
webs  of  larynx,  223 
Cords,  vocal,  53.     See  also  Vocal  cords. 
Coring  method,  Jackson's,  for  removal  of 
multiple    papilloma    in    tracheobron- 
chial tree,  208 
Corks,  extraction  of,  from  bronchi,  172 


Corks  for  occluding  cannula  in  training 
patients  to  breathe  through  mouth 
again  before  decannulation,  309 
for  tracheotomic  cannulae,  method  of 
making,  310 
Correct    manner    of    holding    broncho- 
scope, 102 
Cough  as  symptom  of  esophageal  lodged 
foreign  body,  184 
reflex  as  watch  dog  of  lungs,  284,  298 

total  abolition  of,  65 
sedatives    or    narcotics    in    tracheot- 
omy, 284,  289 
Cramp  of  diaphragmatic  pinchcock,  250 
Crayon    sketches,    colored,    as    aid    to 
accurate    observation    of   larynx,    82 
Crico-arytenoid  joints,  ankylosis  of,  302 
Cricoid  cartilage,  anatomy,  52 
Cricopharyngeal  constriction,  anatomy 
of,  60 
muscle,  60 

spasmodic  stenosis  of  esophagus,   245 
cause,  246 
diagnosis,  246 
symptoms,  245 
treatment,  246 
Cricopharyngeus,  foreign  bodies  below, 
forceps    for   esophagoscopic    removal 
of,  36 
Curette,  laryngeal,  Mosher's,  41 
Current,  commercial,  danger  from,  26 
Curved  position  of  cervical  spine,  with 
anterior  convexity  in  Rose  position,  75 
Cystoma  in  larynx,  201 

Dean,  257 

Decannulation  after  cure  of  laryngeal 
stenosis,  309 
tracheotomy  done  for  papillomata, 
302 
diphtheria  preventing,  304 
in  compression  stenosis  of  trachea,  302 
in  neoplastic  case,  302 
in  tracheotomy,  291 

panic  in,  300 
tuberculosis  preventing,  304 
typhoid  fever  preventing,  305 
Defects,  electric,  testing  for,  118 


INDEX 


321 


Delavan,  202,  213 

Dental  defects,  repair  of,  before  endo- 
scopic procedures,  48 
Deviation  of  esophagus,  272 
Diagnostic    laryngoscope,    infant's,    18, 

19 
Diaphragm,    rubber,    with    perforation 
for  forceps  for  esophagoscope  for  air 
insufflation,  24,  25 
Diaphragmatic  pinchcock,  61,  62,   247 
cramp  of,  250 
stenosis,  247,  250 
Diet  in  gastrostomy-fed  patients,  256 
DifTuse  dilatation  of  esophagus,   244 

treatment,  244 
Digestion  of  esophagus,  238 
Dilatation  of  cicatricial  stenosis  of  eso- 
phagus by  endoscopic  method,  43 
of  esophagus,  diffuse,  244 
treatment,  244 
Dilators,  bronchial,  Jackson's,  37,  40 
self-expanding,  Jackson's,  37,  42 
esophageal,  43 

soft-rubber     retrograde     for    gastro- 

stomized  cases,  43 

Dimensions  of  trachea  and  bronchi,  56 

Diphtheria  antitoxin  in  doubtful  cases 

of  diphtheria,  226 

in  laryngeal  diphtheria  simulating 

foreign  body,  156 
in  tracheobronchial  diphtheria,  227 
influenzal,  tracheobronchitis  and,  dif- 
ferentiation, 226 
laryngeal,  simulating  foreign  body  in 

larynx,  156 
preventing  decannulation,  304 
tracheobronchial,  227 
Direct     laryngoscopy,     82.     See     also 

Laryngoscopy,  direct. 
Direction  of  esophagus,  61 
Disease,  bronchoscopic  appearances  in, 
224 
bronchoscopy    in,    contraindications 
for,  224 
indications  for,  224 
Disimpaction  of  tightly  fitting  foreign 
bodies  in  bronchi,  lip  of  bronchoscope 
for,  172 


Diverticulum   of   esophagus,    260.     See 
also  Esophagus,  diverticulum  of. 
pulsion,    60.     See     also     Esophagus, 

diverticulum  of,  pulsion. 
traction,  260 
Divulsor,  endoscopic,  Jackson's,  41 

Mosher's,  249 
Dog,  Jackson's  mouth  gag  for,  123 

practice  on,  122 
Double    pointed    tacks    in    esophagus, 
removal  of,  194 
removal  of,  171 
Double-planed  fiuoroscope,  Manges,  276 
Down-jaw  esophageal  forceps,  Jackson's, 

36 
Drainage  bronchoscope,  19,  20 
when  used,  21 
canal,  espophagoscope  with,   23 

laryngoscope  with,  18 
of     pulmonary     abscesses,    drainage 

bronchoscope  for,  19 
of  retropharyngeal  abscesses,  aspirat- 
ing tube  for,  28 
outlets,  importance  of  size,  position, 
and  shape  of,  on  bronchoscopes  and 
esophagoscopes,  21 
salivary,  in  absolute  atresia  of  esopha- 
gus, 259 
tubes  as  foreign  bodies,   199 
Drowned  lung,  120 

in  complete  bronchial  obstruction, 

139 
in  foreign  body  in  bronchi,  179 
Drowning  of  patient  in  his  own  secre- 
tions, 154,  230 
following  bronchoscopy,  154 
Dry   cells   of   battery,    renewal   of,    51 
Duodenal  feeding  tube,  passage  of,  198 
Dysphagia,  causes,  235 
diagnosis,  236 

early  and  careful  investigation  of,  217 
from     esophageal     lodged     foreign 

bodies,  184 
palliation  of,  in  tuberculous  or  malig- 
nant disease,  amputation  of  epig- 
lottis for,  93 
Dyspnea,  anesthetic  in,  65 

following  bronchoscopy,  causes  of,  154 


322 


INDEX 


Dyspnea  from  esophageal  lodged  foreign 
body,  184 
in  children  from  large  esophagoscope,  24 

Edema,  angioneurotic,  233 
involving  esophagus,  272 
annular,  above  tightly  fitting  foreign 

body,  172 
chronic  subglottic,  in  children  follow- 
ing  diphtheria,   galvano-cauteriza- 
tion  for,  94 
of  larynx,  277 

subglottic,    after   bronchoscopy,    154 
treatment,  155 
chronic,  cauterization  for,  221 
occurring     in     previously     normal 
larynx,  causes  of,  155 
supraglottic,  following  bronchoscopy, 

154 
Edematous   tracheobronchitis,    226 

resulting  from  aspiration  of  irritat- 
ing liquids  or  vapors,  and  organic 
substances,  227 
Efficient  use  of  forceps,  119 
Electric  aspirators,  28 

defects,  testing  for,  118 
Electrode,  cautery,  flat  blade,  Jackson's 
41 
pointed,  41 
Electrolysis    in    cicatricial    stenosis  of 

esophagus,  257 
Elsberg,  29 

apparatus,  insufflation  anesthesia  by, 

97 
Emergency  tracheotomy,  287.     See  also 

Tracheotomy,    emergency. 
Emphysema,    acute    obstructive,    pro- 
duced    by    expiratory     valve-like 
bronchial  obstruction,  138,  139 
gaseous,  treatment,  198 
subcutaneous,  239 
Enchondroma  in  larynx,  202 
Endobronchial    secretions,    diminution 

of,  atropin  and  morphin  for,  65 
Endogastric  version  for  removal  of  open 

safety  pin  in  esophagus,  193 
Endolaryngeal     extirpation     of     papil- 
loma in  children,  204 


Endolaryngeal  operations,  after-care  of, 
96 
complications  after,  96 
during,  96 
Endoscopic  aspirating  tube,  protected- 
aperture,  28 
battery,  Jackson's,  27 
sterilization  of,    27 
bougies,    Jackson's,    46 
closure  of  open  safety  pin  lodged  point 

upward,  Jackson's  method,  42,  44 
divulsor,  Jackson's,  41 
evisceration  of  larynx  for  laryngeal 

cicatricial    stenosis,    94 
foreign  body  extraction,  rules  for,  1 74 

use  of  forceps  in,  i6i,  162 
method   for   dilatation   of   cicatricial 

stenosis  of  esophagus,  43 
operating  room,  47 
operations,  after-care,  96 

for  laryngeal  stenosis,  94 
picture  of  compression  stenosis,  225 
procedures,  asepsis  in,  47,  48 
preparation  of  patient  for,  48 
respiratory  arrest  during,  48 
removal     of     hollow-foreign     bodies, 

expansile  forceps  for,  36 
side-curved  forceps,  Jackson's,   jaws 

of,  34 
sponges,  pattern  for,  31 

sterilization  of,  32 
table,  46 
team,  47 

tissue  forceps,  Jackson's,  38 
view  at  end  of  first  stage  of  direct 
laryngoscopy,  84 
of  second  stage  of  direct  laryngo- 
scopy, 86 
Endoscopist,    difficulties   pertaining  to, 

88 
Endoscopy,  acquiring  skill  in,  117 
batteries  for,  26 
faulty  position  for,  79,  80 
in  malignant  disease  of  larynx,   210 
instructions  to  patient  before,  83 
on  human  being,  124 
peroral,  anesthesia  for,  65 
position  of  patient  for,  73 


INDEX 


323 


Endoscopy,     peroral,     preparation     of 
patient  for,  63 
portable  aspirator  for,  29 
schema  of  position  for,  78 
Endotracheal    anesthesia    for    adminis- 
tration of  ether,  advantages  of, 
67,  68 
indications  for,  69 
rules  for  insertion  of  catheter  for,  69 
Endotracheobronchial  secretions,  aspira- 
tion of,  during  bronchoscopy,  aspirat- 
ing tube  for,  28 
Epiglottis,  amputation  of,  for  palliation 
of    odynphagia    or    dysphagia    in 
tuberculous  or  malignant  disease,  93 
anatomy,  52 

bringing  foreign  body  through,   me- 
chanical problems  of,  164 
function  of,  93 
malignant  disease  of,  210 
removal     of     portions     from,     large 
basket  punch  forceps  for,  39 
Epithelioma   of   esophagus,    squamous- 

celled,  216 
Errors   to   avoid   in   suspected   foreign 

body  cases,  142 
Esophageal   antiperistalsis,    250 

bougie,  retrograde,  Jackson  and  Tuck- 
er's, 41 
dilators,  43 

down-jaw  forceps,  Jackson's,  36 
intubation   in    malignant   disease   of 
esophagus,  219 
tube,  Charters-Symonds,  219 
Guisez,  219 
lesions,  measuring  rule  for  locating,  26 
lumen,  diameter  of,  59 
mucosa,  normal,  appearance,  112 
narrowings  from  upper  incisor  teeth, 
esophagoscopic    chart   of    approxi- 
mate distances  of,  58 
speculum    and    hypopharyngoscope, 
Jackson's,  23 
adult's  size,  23 
as  pleuroscope,  25,  26 
child's  size,  23 

for    operations    on    upper    end    of 
esophagus,  25 


Esophageal   speculum   for    removal   of 
foreign  bodies,  190 

Jackson's,  23 
stenosis,  Jackson's  sign  of,  237 
symptoms  in  foreign  body  cases,  148 
wall,  risk  of  perforating  in  introducing 

esophagoscope,  24 
Esophagismus,  hiatal,  62,  247 

diagnosis,  248 

symptoms,  247 

treatment,  249 
Esophagitis,  acute,  239 

endoscopic  appearances  in,  239 

treatment,  197 
chronic,  242 

traumatic,  treatment,  239 
treatment,  187 
Esophagoscope,  21 
adult's  size,  22,  23 
angle  of,  in  facilitating  introduction 

of,  24 
child's  size,  22,  23 
entering  right  pyriform  sinus,  107" 
for  admitting  largest  esophagoscopic 

bougies,  22 
full  lumen,  22 
heavy  handled  short,  23 
with  drainage,  23 
importance  of  size,  position  and  shape 

of  drainage  outlets  on,  2 1 
introduction  of,  106 

position  for,  106 

stages,  106 
Jackson's,  22 

large,  dyspnea  from,  in  children,  24 
passing  the  cricopharyngeus,  108 

through  hiatus  esophageus,  iii 
thoracic  esophagus,  in 
retrograde,  Jackson's,  22,  47 
risk  of  perforating  esophageal   wall 

in  introduction  of,  24 
rubber  diaphragm  for,  with  perfora- 
tion for  forceps  for  air  insufflation, 

24,  25 
short,  Jackson's,  23 
sizes  required,  23 
slant  of,  in  facilitating  introduction  of, 

24 


324 


INDEX 


Esophagoscope,  special  size,  22,  24,  25 
window-plug  for,  in  ballooning  esopha- 
gus.   24,  25 
Esophagoscopic  appearances  of  malig- 
nant disease  of  esophagus,  218 
aspiration,     Robinson's     mechanical 

aspirator  for,  29 
bougies,    large,    esophagoscopes    for 

admitting,  22,  24 
chart    of    approximate    distances    of 
esophageal  narrowings  from  upper 
incisor  teeth,  58 
extraction  of  foreign  bodies,  188 
anesthesia  in,  190 
below  cricopharyngeus,  forceps 

for,  36 
mechanical  problems  of,  190 
of  safety  pins,  rotation  forceps  for, 

34 
grasping  forceps,  33 
mechanical  spoon,  Jackson's,  42,  45 
perforation,  point  of,  60 
table,  Jackson's,  46 
views   from   oil-color   drawings   from 

life  by  Jackson,  Plate  III,  facing  p. 

106 
Esophagoscopy,  ballooning,  114 
Boyce  position  for,  77 
chloroform  in,  67 
complications  following,  115 
contraindications  for,  236 
correct  position  of  cervical  spine  for, 

74 
difficulties  of,  113 
fluoroscopic,   in  extraction  of  foreign 

body  from  esophagus,  196 
for  foreign  body  in  esophagus,  187 

complications  and  dangers,  197 
contraindications    for,    187 
indications  for,  187 
overriding  in,  189 
general  anesthesia  in,  technic,  67 
in  esophageal  disease,  indications  for, 

236 
Jackson's  high-low  method,  106,  108, 

112 
obstruction  of  canal  during,  23 
position  for,  76 


Esophagoscopy,  position  of  patient  for, 
46 
preliminary  examination  of  pharynx 
and  larynx  with  tongue  depressor, 
237 
removal  of  food  particles  during,  113 
retrograde,  115,  116 
in  cicatricial  stenosis  of  esophagus, 
258 
secretions  during,  aspiration  of,   112 
specular,  114 

technic,  114 
water  starvation  as  contraindication 
to,  236 
Esophagotomy,  external,  in  foreign  body 
in  esophagus,  185 
internal,    in    cicatricial     stenosis    of 
esophagus,  257 
Esophagotracheal  fistula,  congenital,  237 
Esophagus,  actinomycosis  of,  272 

acute  and  subacute  inflammation  and 

ulceration  of,  treatment,  242 
anatomy,  57 
and   trachea,    intra-thoracic,   normal 

position  of,  73 
angioma  of,  271 
angioneurotic  edema  of,  272 
anomalies  of,  237 
treatment,  238 
aortic  narrowing  of,  60 
atresia  of,  absolute,  salivary  drainage 

in,  259 
ballooning  with  air,  window  plug  for 

esophagoscope  in,  24,  25 
benign  neoplasms  of,  209 
broad  flat  bodies  with  sharp  point 

removal  of,  191,  192 
bronchial  narrowing  of,  60 
cancer  of,  216 
cicatricial  stenosis  of,   dilatation  of, 

by  endoscopic  method,  43 
cricopharyngeal    spasmodic    stenosis 
of,  245 
cause,  246 
diagnosis,  246 
symptoms,  245 
treatment,  246 
deviation  of,  272 


INDEX 


325 


Esophagus,   diameter  at  four  points  of 
anatomical  constriction,  59 
digestion  of,  238 
dilatation  of,  difTuse,  244 

treatment,  244 
direction  of,  61 
diseases  of,  235,  268 

esophagoscopy  in,   indications  for, 
236 
diverticulum  of,  260 
after-care  of,  267 
Boyce  sign  in  diagnosis,  263 
classification  of,  260 
diagnosis,  261,  263 
etiology,  262 

operative  mortality  in,  263 
prognosis,  262 
pulsion,  261 

esophagoscopic    appearances    in, 

264 
Gaub-Jackson  operation  in,   266 
methods    of    external    operation 

for,  265 
treatment  of,  265 
recurrences  in,  263 
symptoms,  263 
traction,  260 
double  pointed  tacks  in,  removal  of, 

194 
emptying    of,    by    regurgitation    in 

preparation  for  endoscopy,  63 
extraction  of  open  safety  pin  from,  192 
of  tooth  plate  from,  196 
of  very  large  bodies  from,  general 
anesthesia  for,    194 
foreign  body  in,  183 

esophagoscopy  for,  187 
contraindications  for,  187 
indications  for,  187 
etiology,  183 

external  esophagotomy  in,  185 
physical  signs  in,  132 
prognosis,  184 
prolonged    sojourn    of,    stricture 

after,  196 
site  of  lodgment,  183 
symptoms,  127,  184 
treatment,  185 


Esophagus,    functional    hiatal    stenosis 

of,  247,  250 
horizontally     transfixed     bodies     in, 

removal  of,  190,  191 
imperforate,  237 
intubation  of,  in  cicatricial  stenosis, 

259 
lengths  of,  at  different  ages,  59 
malignant  disease  of,  216 
bouginage  in,  219 
diagnosis,  217 

esophageal  intubation  in,  219 
esophagoscopic     appearance     of, 

218 
gastrostomy  in,  219 
radiotherapy  in,  220 
roentgenray  in,  220 
sites  of  lesion,  216 
symptoms,  216 
treatment,  219 
movements  of,  extrinsic,  61 
intrinsic,  61 
pulsatory,  61 
respiratory,  61 
transmitted,  61 
narrowing  of,  hiatal,  60 
paralysis  of,  268 
diagnosis,  269 

esophagoscopic  findings  in,  269 
etiology,  268 
motor,  268 
sensory,  268 
treatment,  269 
perforation  of,  238 

as    contraindication    to  esophagos- 
copy, 188 
usual  site  of,  60 
points  of  demonstrable  constrictions, 

59 
removal  of  meat  and  other  foods  from, 

196 
rupture  of,  238 

treatment,  239 
site   of   spasmodic   stenosis  in   lower 

third  of,  62 
soft  friable  substances   impacted  in, 

mechanical  spoon  for   removal  of, 

42,  45 


326 


INDEX 


Esophagus,  spastic  stenosis  of,  244 
squamous-celled  epithelioma  of,  216 
staples  in,  removal  of,  194 
stenosis  of,  cicatricial,  251 

differential  diagnosis,   254 

divulsionof  upper  stricture  in,  257 

electrolysis  in,  257 

esophagoscopic    appearances    of, 

254 
bouginage  in,  256 
etiology,  251 
impermeable  strictures  in,  Bren- 

neman's  method  for,  258 
internal  esophagotomy  in,  257 
location  of  strictures,  252 
prognosis,  252 

retrograde  esophagoscopy  in,  258 
salivary    drainage     in    absolute 

atresia  in,  259 
string-swallowing  in,  257 
symptoiris,  254 
thermic  bouginage  in,  257 
treatment,  255 
compression,  243 
appearances  in,  243 
lesions  associated  with,  243 
treatment  of,  243 
Jackson's  sign  of,  268 
spasmodic,  245 

compression  stenosis  simulating, 

249 
etiology,  245 
stricture  of,  congenital,  237 
strictured,  extraction  of  foreign  bodies 

from,  196 
syphilis  of,  269 
diagnosis,  270 

esophagoscopic  appearances  in,  269 
treatment,  270 
trauma  of,  238 
tuberculosis  of,  270 
diagnosis,  271 
treatment,  271 
ulcer  of,  240 

carcinomatous,  241 
differential  diagnosis,  240 
luetic,  240 
sarcomatous,  241 


Esophagus,  ulcer  of,  simple,  240 
tuberculous,  241 
upper  end,  operations  on,  esophageal 

speculum  for,  25 
varix  of,  271 

webs  in  upper  third  of,  238 
Ether,    administration    of,    by    endo- 
tracheal anesthesia,  advantages  of, 
67,  68 
anesthesia  for  ballooning  esophagos- 
copy, 114 
endotracheal   administration   of,   ad- 
vantages of,  67 
insufflation  of,  aspirating  tube  for,  28 
during     bronchoscopy,     apparatus 
for,  29 
Evisceration,  endoscopic,  of  larynx,  for 

laryngeal  cicatricial  stenosis,  94 
Examination,    fluoroscopic,    in    foreign 
body  cases,  138 
mirror,  of  larynx,  importance  of,  82 
of  trachea  and  bronchi,  102 
Expanding  forceps,  36 
Expiratory    valve-like    obstruction    of 
bronchus,  physical  signs 
in,  135 
roentgenographic  signs  of, 
138 
Expulsion,     sponanteous,    of    foreign 

bodies  from  air  passages,  150 
External  esophagotomy  in  foreign  body 

in  esophagus,  185 
Extra  light  forceps,  35 
Extrinsic  movements  of  esophagus,  61 
Extubal  method  of  Jackson  for  removal 
of  tumor  of  upper  part  of  larynx,  93 
Eyes  of  ojjerator,  position  of,  in  operat- 
ing, 45 

False  vocal  cords,  53 

Fatigue  in  children  after  bronchoscopy, 

154 
Faulty  position,  for  endoscopy,  79,  80 
Feeding,  rectal,  in  water  starvation,  237 
Fenestrated  peanut  forceps,  Jackson's,  37 
Fibroma  in  larynx,  201 
Films,     positive,     of     tracheobronchial 

tree  as  aid  to  localization,  140 


INDEX 


327 


Fistula,    esophagotracheal,    congenital, 

237 
Flat  blade  cautery  electrode,  Jackson's 

41 
Fluid     for     preparation     of     cadaver, 

formula,  120 
Fluoroscope,  Manges  double-planed,  276 
fluoroscopic  bronchoscopy,    176 

esophagoscopy  in  extraction  of  foreign 

body  from  esophagus,  196 
examination   in   foreign   body   cases, 

138 
study   of    swallowing    function    with 
barium    mixture    for    location    of 
non-roentgenopaque   object,    138 
Flutter,  tracheal,  in  foreign  body  cases, 

144 
Food   passages,   foreign  bodies  in,   12 
See    also    Foreign    bodies    in   food 
passages. 
regurgitation  of,  from  stomach,  nor- 
mal prevention  of,  62 
Forceps,  32 

alligator,  32,  33 
ball,  Jackson's,  172 
bronchoscopic  grasping,  33 
deliveries,  paralytic  stenosis  of  larynx 

from,  278 
down-jaw  esophageal,   Jackson's,    36 

Jackson's,  190 
fenestrated  peanut,  Jackson's,    37 
forward  grasping  tube,   Jackson's,  33 
efficient  use  of,  119 
esophagoscopic  grasping,  :i3 
expanding,  36 
extra  light,  35 

insertion  of,  judging  distance,  119 
large  basket  punch,  38 
laryngeal  rotation,  34 
Jackson's,  40 
tissue,  extra  large,  40 
light  reflex  on,  in  gauging  depth  of 

insertion  of  instruments,  160 
mosquito,  35 

papilloma,  Jackson's,  39,  40 
proper  hold  of,  162 
rotation,  Jackson's,  34    • 
screw,  36 


Forceps,  side-curved  endoscopic,  Jack- 
son's, jaws  of,  34 
side-grasping  tube,  Jackson's,  23t  34 
square-cannula,  35 
sterilization  of,  49 
strengths  of,  161 
stripping  foreign  body  from,  at  glottis, 

164 
stylets,  cleaning  of,  51 
thread  practice  with,  119 
tissue,  endoscopic,  Jackson's,  37 
Tucker,  36,  167,  192,  193 
jaws  for  Jackson's,  35 
upper-lobe-bronchus,  35 
use  of,  in  foreign  body  extraction,    161 

162 
vocal-nodule,  Jackson's,  40 
Foreign  body,  anchoring  against   tube 
mouth,  method  of,  163 
and    tube    mouth,    relation   of,    in 

foreign  body  problems,  160 
being  coughed  out,  possibility  of,  181 
below  cricopharyngeus,  forceps  for 

esophagoscopic  removal  of,  36 
bronchoscopic  finding  of,  152 
bronchoscopy  for,  best  time  for,  152 
morphin  and  atropin  for,  65 
unsuccessful,  181 
downward  movement  of,  184 
drainage  tubes  as,  199 
esophageal  speculum  for  removal  of, 

190 
esophagoscopic  extraction  of,  188 

overriding  in,  189 
esophagoscopy  for,  187 
contraindications  for,  187 
indications  for,  187 
extraction,  bronchoscopic,  mechan- 
ical problems  of,  158 
anchoring     foreign     body 
against  tube  mouth,  162 
animal  objects  from  tra- 
cheobronchial tree,  174 
bringing      foreign      body 

through  glottis,  164 
double  pointed  tacks,  171 
foreign   bodies   in   upper- 
lobe  bronchus,  174 


328 


INDEX 


Foreign  body  extraction,  bronchoscopic, 

mechanical  problems  of, 

hollow  metallic   bodies, 

167 
hooks  in,  161 
inward    rotation    method, 

165, 166 
light  reflex  on  forceps,  160 
lip  of  bronchoscope  in,  160 
open     safety     pins     from 

trachea  and  bronchi,  169 
overriding,    164 
penetrating  projectiles,  1 74 
pins,  needles  and  similar 

long     pointed     objects, 

164,  165 
presentation  in,  study  of, 

159 
relation  of  tube  mouth  and 

foreign  body,  160 
rubber-tube  manikin  prac- 
tice in,  158 
rules  for,  1 74 
soft  friable  foreign  bodies 

from     tracheobronchial 

tree,  173 
study    of    roentgenograms 

in,  158 
tacks,     nails,     and     large 

headed   foreign   bodies, 

167 
tightly      fitting      foreign 

bodies  from  bronchi,  172 
use  of  forceps  in,  161 
endoscopic,  rules  for,  1 74 
esophagoscopic,     anesthesia     in, 
190 
mechanical  problems,  190 

broad,    flat    bodies,    with 

sharp  point,  191,  192 
complications  and  dangers, 

197 
double  pointed  tacks  and 

staples,  194 
endogastric    version,    193 
fluoroscopic        esophagos- 

copy,  196 
from  strictured  esophagus, 

196 


Foreign    body    extraction,    esophagos- 
copic, mechanical  prob- 
lems, general  anesthesia 
for  large  bodies,  194 
horizontally  transfixed 

bodies,  190,  191 
meat  and  other  foods,  196 
open  safety  pins,  192 
prolonged       sojourn       of 
bodies  in  esophagus,  196 
spatula-protected  method, 

193 
treatment     of     complica- 
tions, 197 
version  of  safety  pin,  193 
very  large  size  bodies,  194 
from  larynx,  modified  Trendelen- 
burg position  for,  81 
inward  rotation  method  of  Jack- 
son's for,  165,  166 
use  of  forceps  in,  161,  162 
gastroscopy  for,  275 
hollow,     endoscopic     removal     of, 

expansile  forceps  for,  36 
in  air  passages,   126 

bronchial  symptoms,  145 
diagnosis,  131 
esophageal  symptoms,  148 
general    physical    examination 

in,  132 
initial  symptoms,  143 
laryngeal  symptoms,  143 
physical  signs  in,  145 
prophylaxis,  126 
roentgenray  in  diagnosis,   148 
tracheal  symptoms,  144 
in  bronchus,  asthmatoid  wheeze  in, 
136  ♦ 

for  prolonged  periods,  177 

bronchoscopy  for  diagnosis, 

177,  179 
gravity  of,  178 
pathology,  178 
prognosis,  179 
symptoms,  129 
time  of  aspiration,  177 
treatment,  179 
tubercular  sjonptoms  in,  177 
physical  signs,  134 


INDEX 


329 


Foreign  body  in  bronchus,  physical  signs, 
in  complete   bronchial 
obstruction,  135 
in  expiratory  valve-like  ob- 
struction, 135 
in  partial  bronchial  obstruc- 
tion, 136 
prolonged    obstruction    in,     137 
symptoms,  128 
in  esophagus,  183 
esophagoscopy  for,  187 
etiology,  183 

external   esophagotomy   in,    185 
physical  signs  in,  132 
prognosis,  184 
prolonged    sojourn    of,    stricture 

after,  196 
site  of  lodgment,  183 
symptoms,  127,  184 
treatment,  185 
in  food  passages,  126 

bronchial  symptoms,    145 
diagnosis,  131 
esophageal  symptoms,  148 
general    physical    examination 

in,  132 
initial  symptoms,  143 
laryngeal  symptoms,  143 
physical  signs  in,  145 
prophylaxis,  126 
roentgen  ray  in  diagnosis,  148 
tracheal  symptoms,  144 
in  the  insane,  127 
in  larynx,  133,  149 
diagnosis,  155 
laryngeal  diphtheria  simulating, 

156 
removal  of,  156 
anesthesia  for,  157 
diagnosis,  156 
position  for,  156 
preliminary  examination,    156 
ronetgenogram  as  preliminary, 

156 

symptoms,  156 

technic,  156 
site  of  lodgement,  149 
symptoms,  156 


Foreign  body  in  pleural  cavity,  199 
in  stomach,  127 

symptoms,  131 
in  trachea,  physical  signs,  133 

symptoms,  128 
tracheobronchial  tree,  149 

site  of  lodgment,  149 
in  upper-lobe  bronchus,  forceps  for, 

35 
removal  of,  1 74 

irregular,  in  larynx,  rotation  forceps 
for  removal  of,  34 

irregularly  shaped,  rotation  forceps 
for  traction  on,  34 

irritating,  such  as  peanut  kernel  in 
bronchus,  early  symptoms  of,  129 

lip  of  bronchoscope  in  disimpaction 
of,  172 

of  soft  surface  consistency,  aspirat- 
ing tube  for  removing,  28 

secretions  lying  close  to,  removal  of, 
aspirating  tube  for,  28 

signs  suggestive   of,   146 

soft  friable,  extraction  from  tracheo- 
bronchial tree,  173 

spontaneous  expulsion  of,  from  air 
passages,  150 

strictures  above,  bronchial  dilators 
for,  37,  40 

stripping  of,  from  forceps  at  glottis, 
164 

suspected,  indications  for  bronchos- 
copy for,  151 

symptomatology  of,  127 

thoracotomy  for,  182 

tracheotomy  for,  279 

with  secretions,  drainage  broncho- 
scope for,  19 

work,  esophageal  sf>eculum  for,  25 
fluoroscopic  examination  in,  138 
roentgenray  study  in,  137 
in  larynx,  grasping  forceps  for,  23 
in  suspected  cases,  errors  to 
avoid,  142 
Formaldehyde  pastilles  for  continuous 

sterilization  box,  49,  51 
Formula   for   fluid   for  preparation   of 
cadaver,  120 


33° 


INDEX 


Freer,  95 

Freer's  method  of  radiation  from  pyri- 

form    sinus   in   malignant   disease   of 

larynx,  213 
Fulcrum  of  bronchoscopic  lever,  position 

of,  103 
Fulguration  for  papilloma  of  larynx  in 
■    children,  204 

I'uU  lumen  esophagoscope,  22 
Functional  hiatal  stenosis,  62 
of  esophagus,  247,  250 

Gag,  mouth,  Jackson's  for  use  on  dog,  1 23 

Gagging,  wide,  prevention  of  exposure 
of  larynx  by,  32 

Galvanocauterization  for  chronic  sub- 
glottic edema  or  hyperplasia  in  chil- 
dren following  diphtheria,  94 

Galvanocautery  for  sessile  vocal  nodules, 
201 
puncture  for  tuberculous  infiltrations 
of  larynx,  95 

Galvanopuncture  for  laryngeal  tubercu- 
losis, 222 

Gangrene  of  lung,  229 

Gaseous    emphysema,    treatment,    198 

Gases,  irritant,  poisoning  by,  bronchial 
aspiration  and  bronchoscopic  oxygen 
insufflation  in,  291 

Gastric  foreign  body,  symptoms,  131 
mucosa,   appearance,    112 

Gastroscope,  lens-system,  Janeway,  275 

Gastroscopes,    25 

Gastroscopic  view  of  a  gastro-jejunos- 
tomy  opening  drawn  patulous  by 
tube  mouth,  reproduction  of  Jackson's 
oil-color  drawing  from  life,  Plate  IV, 
facing  p.  273 

Gastroscopy,  273 
anesthesia  in,  273 
ballooning  stomach  in,  274 
chloroform  in,  67 
for  foreign  bodies,  275 
general  anesthesia  in,  technic,  67 
lens-system  ballooning,  275 
technic,  273 

Gastrostomy  for  feeding  as  preliminary 
to  esophageal  operation,  267 


Gastrostomy   in   malignant   disease   of 
esophagus,  219 
in  serious  degrees  of  esophageal  trauma , 

198 
in  water  starvation,  237 
indications  for,  127 
soft-rubber    retrograde    dilators    for, 

43 
Gastrostomy-fed  patients,  diet  in,   256 
Gaub-Jackson     operation     in     pulsion 

diverticulum  of  esophagus,  266 
Gauging  depth  of  insertion  of  instru- 
ments, light  reflex  for,  160 
Gauze  sponges,  method  of  making,  32 

sterilization  of,  32 
Globus  hystericus,  246 
Glottis,     adult     anterior     commissure 

laryngoscope  for  work  in,  19 
Goiter   operations,    endotracheal   anes- 
thesia in,  68 
examination  of  patient  with  throat 
mirror  before,  68 
Graham,  256 

Granuloma  in  larynx,  201 
Grounding  of   circuit  through  patient, 

danger  of,  26 
Groves,  259 

Growths,   benign    in   lar3aix,    201,    206 
removal  of,  91 
in   tracheobronchial  tree  bronchos- 
copic removal  of,  207 
symptoms  of,  207 
in  anterior  portion  of  larynx,  removal 

of,  91 
in  laryngeal  ventricle,  removal  of,  92 
•   laryngeal,  in  larynx  of  adults,  differ- 
ential diagnosis  of,  211 
malignant,  of  trachea,  bronchoscopy 
in,  214 
radium  in,  215 
treatment,  214 
pedunculated  subglottic,  removal  of, 

91 
primary     in     tracheobronchial     tree, 
benign,  207 
Guisez,  229 

Guisez's    esophageal    intubation    tube, 
219 


INDEX 


331 


Gums,  mouth,  and  lips  of  child,  wound- 
ing of,  90 

Hand  aspirator,  28 
Hemoptysis,  233 

Hemorrhage,  morphin  in  controlling,  96 
within  larynx,  method  of  stopping,  96 
Hemostasis,    pulmonary,    by    broncho- 
scopic   tamponade,  Jackson's  tam- 
pon for,  232 
Hiatal  esophagismus,  62,  247 
diagnosis,  248 
symptoms,  247 
treatment,  249 
narrowing  of  esophagus,  60 
stenosis,  functional,  62 

of  esophagus,  functional,  247,  250 
Hiatus  esophageus,  6i 
Hiding  of  coin  by  folding  downward  of 

plica  cricopharyngeus,  189 
High  head  position  with  occipito-atloid 

extension,  obtaining,  79 
High-low    method    of    esophagoscopy, 

Jackson's,  106,  108-112 
Hollow   foreign   bodies,   endoscopic    re- 
moval of,  expansile  forceps  for,  36 
metallic  bodies,  extraction  of,  mechan- 
ical problem  of,  167 
Hook    in   extraction   of    tightly   fitting 
foreign  bodies  in  bronchi,  172,  173 
temple  frames  for  spectacles,  45 
Hooks,  43 

coil-spring,  44 

for  upper-lobe-bronchus,  Tackson's, 

44 
half-curved,  43 
spiral  twist,  44 
in  solution  of  mechanical  problems,  161 

Human  being,  endoscopy  on,  125 

Hyperplasia  in  children  following  diph- 
theria, galvano-cauterization    for,    94 

Hyperplastic     and     cicatricial     chronic 
stenoses  preventing  decannulation,  303 

Hypodermoclysis,  187 

Hypopharyngoscope     and     esophageal 
speculum,  Jackson's,  23 

Iglaner,  138 


Imperatori,  257 

Imperforate    esophagus,     237 

Importance    of    mirror   examination    of 

larynx,  82 
Incorrect   manner  of   holding  broncho- 
scope, 102 
Inducing  child  to  open  mouth,  Jackson's 

method,  90 
Infant's  diagnostic  laryngoscope,  18,  19 

size  bronchoscope,  20,  21 
Influenza,  226 

Influenzal  laryngotracheobronchitis,  226 
tracheobronchitis,      diphtheria     and, 
differentiation,  226 
Insane,  foreign  bodies  in,  127 
Insertion    of    catheter    for    insufflation 

anesthesia,  rules  for,  69 
Inspection  of  party  wall  in  suspected 

laryngeal  malignancy,  212 
Intra-thoracic   trachea   and   esophagus, 

normal  position  of,  73 
Instructions    to    patient    before    endo- 
scopy, 83 
Instrument  nurse,  50 
Instruments,  arrangement  of,  in  opera- 
ting room,  417 
care  of,  50 

for  direct  laryngoscopy,  88 
list  of,  49 
sterilization  of,  49 
tracheotomy,  48 
Instrumentarium,  17 
Insufflation,     air,     rubber     diaphragm 
with    perforation    for    forceps    for 
esophagoscope  in,  24,  25 
anesthesia,  insertion  of  catheter  for, 
rules  for,  69 
with  Elsberg  apparatus,  97 
intratracheal,  anesthesia  by,  in  par- 
alysis of  larynx,  68 
of  ether,  aspirating  tube  for,  28 
or  chloroform  during  bronchoscopy, 
apparatus  for,  29 
of  oxygen,  bronchoscope  for,  19 
bronchoscopic,  71 
Internal  bronchotomy,  180 
Intratracheal  insufflation,  anesthesia  by, 
in  paralysis  of  larynx,  68 


332 


INDEX 


Intrinsic  movements  of  esophagus,  6i 
Intubating  laryngoscope,  i8 
Intubation   of   esophagus   in  cicatricial 
stenosis,  259 
in  malignant  disease  of  esophagus, 
219 
tube,     retaining,     for    treatment    of 
chronic    laryngeal    stenosis,    Jack- 
son's, 307 
tubes,  endoscopic  removal  of,  expan- 
sile forceps  for,  36 
Intubational  treatment  of  chronic  laryn- 
geal stenosis,  307 
Inward    rotation    method    of    foreign 

body  extraction,  Jackson's,  165,  166 
Irritating  foreign  body  such  as  peanut 
kernel  in  bronchus,  early  symptoms 
of,  129 

Jackson  and  Tucker's  retrograde  eso- 
phageal bougie,  41 
Jackson's  ball  forceps,  172 

bronchial  dilators,  37,  40 

bronchoscopes,  20 

bronchoscopic  mechanicalspoon,  42, 45 
table,  46 

coil-spring  hook  for  upper-lobe-bron- 
chus, 44 

coring  method  for  removal  of  multiple 
papilloma  in  tracheobronchial  tree, 
208 

down-jaw  esophageal  forceps,  36 
forceps,  190 

endogastric  version  method  for  re- 
moval of  upward  pointed  open 
safety  pin  in  esophagus,  194 

endoscopic  battery,  27 
bougies,  46 
divulsor,  41 
tissue  forceps,  38 

tubes  for  laryngoscopy,  bronchos- 
copy, esophagoscopy  and  gastros- 
copy.    Plate  I,  facing  p.  52 

esophageal  specula,  23 

and  hypopharyngoscope,  23 

esophagoscopes,  22 

esophagoscopic  mechanical  spoon,  42, 
45 


Jackson's  esophagoscopic  table,  46 
extubal  method  for  removal  of  tumor 

of  upper  part  of  larynx,  93 
fenestrated  peanut  forceps,  37 
flat  blade  cautery  electrode,  41 
forceps.  Tucker  jaws  for,  35 
forward-grasping  tube  forceps,   33 
high-low   method   of   esophagoscopy, 

106,  108-112 
inward   rotation  method  for  extrac- 
tion of  foreign  bodies,  165,  166 
laryngeal  bougie,  46 

rotation  forceps,  40 
laryngoscopes,  17,  18 
long  cane-shaped  tracheal  cannula,  215 
malleable      tracheotomic     aspirating 

tube,  28 
method  of  bronchial  mapping,    141, 
142 
of     endoscopic     closure     of     open 
safety  pin  lodged  point  upward, 
42,  44 
of  inducing  child  to  open  mouth,  90 
of  laryngostomy,  306 
mouth  gag  for  use  on  dog,  123 
papilloma  forceps,  39,  40 
position  for  removal  of  foreign  body 

from  larynx,  80 
protected-aperture  endoscopic  aspira- 
ting tube,  28 
retaining  intubation  tube  for  treat- 
ment of  chronic  laryngeal  stenosis, 

307 

retrograde  esophagoscope,  22,  47 

rotation  forceps,  34 

self-expanding  bronchial  dilator,  37, 
42 

short  esophagoscopes,  23 
mechanical  spoon,  39 

side-curved  endoscopic  forceps,  jaws 
of,  34 

side-grasping  tube  forceps,  33,  34 

sign  of  esophageal  stenosis,  237,  268 

solution  of  upper-lobe-bronchus  prob- 
lem with  mushroom  problem  com- 
bined, 169 

tampons  for  pulmonary  hemostasis  by 
bronchoscopic  tamponade,  232 


INDEX 


333 


Jackson's  tracheotomic  cannulae,  282 
triangle,  286 

two-stage  finger  guided  method  of 
emergency  tracheotomy,  287 

upper-lobe  bronchus  forceps  in  ex- 
traction of  pin  in  anteriorly  ascend- 
ing branch  of  upper  lobe  bronchus, 

174 
vocal-nodule  forceps,  40 
Janeway   lens-system   gastroscope,    275 
Jaws    of    Jackson's    side-curved    endo- 
scopic forceps,  34 
Tucker,  for  Jackson's  forceps,  35 
Johnston,  195 

Kelofdal  scars,  advisability  of  removal 

of,  209 
Knife,  laryngeal,  41 
Knives,  sterilization  of,  49 
Kyphosis,  escopagoscopy  in,  113 

Lamps,  over-illuminating,    as  cause  of 
trouble,  117 

sterilization  of,  49 

testing,  118 
Large  basket  punch    forceps,  38 

esophagoscopes,  dyspnea  from  in 
children,  24 

headed  foreign  bodies,  extraction  of, 
from  tracheobronchial  tree,  Jack- 
son's inward  rotation  method  for,  167 

lumen  laryngoscope,  18 
Laryngeal  and  tracheal  stenoses,  repro- 
ductions    of     Jackson's     oil-color 
drawings  from  life,  Plate  V,  facing 
p.  300 

bougie,  Jackson's,  46 

cicatricial  stenosis,  endoscopic  evis- 
ceration of  larynx  for,  94 

curette,  Mosher's,  41 

diphtheria  simulating  foreign  body 
in  larynx,  156 

grasping  forceps,  Mosher's,  32 

growths,    grasping     forceps    for,    32 
in    larynx    of    adults,    differential 
diagnosis  of,  211 

knife,  41 

operation  and  bronchoscopy,  anesthe- 
tic technic  in,  66 


Laryngeal   operation,  technic  of,  91 
paralysis  associated  with  compression 

stenosis  of  esophagus,   243 
perichondritis,  acute  laryngeal  steno- 
sis in  infants  from,  278 
rotation  forceps,  34 

Jackson's,  40 
specimen  for  diagnosis,  taking  of,  92 
stenosis  endoscopic  operations  for,  94 
stridor,  congenital,  222 

treatment,  223 
symptoms  in  foreign  body  cases,  143 
tissue  forceps,  extra  large,  40 
ventricle,   removal  of   growths   from, 

29 
views,  direct  and  indirect,  from  Jack- 
son's oil-color  drawings  from  life, 
Plate  II,  facing  p.  82 
Laryngoscope,  17,  18 
adult's  size,  18 
anterior  commissure,  18,  19 

as  pleuroscope,  19,  26 
child's  size,  18 

as    esophageal    speculum    in    in- 
fants, 190 
direct,  introduction  of,  and  exposure 
of  larynx,  first  stage,  84 
second  stage,  84 
German  method  of  introducing,  84 
infant's  diagnostic,  18,  19 
intubating,  18 
Jackson's,  17,  18 
large  lumen,  18 
side-slide,  19 
tubular,  19 

with  drainage  canal,   18 
Laryngoscopy,  direct,  82 
after-care,  96 

and  exposure  of  larynx,  first  stage, 
84 
second  stage,  84 
aspiration  of  pharyngeal  secretions 

during,  aspirating  tube  for,  28 
contraindications  to,  83 
difficulties  of,  88 

endoscopic   view    at    end    of    first 
stage,  84 
of  second  stage,  86 


334 


INDEX 


Laryngoscopy,  direct,  in  adult  patient, 

83 
in  children,  89 
anesthesia  in,  67 

without  anesthesia,  reasons  for,  90 
in  diseases  of  larynx,  221 

anesthesia  in,  221 
instruments  for,  88 
on  recumbent  patient,  schema  illus- 
trating technic,  85 
position  for,  76 
removal  of  secretions  by  aspirator 

during,  87,  91 
rules  for,  86 
state  of  spasm   of  larynx  in    first 

view,  86 
vocal  results  after,  94 
for  application  of  radium  in  malignant 

disease  of  larynx,  212 
indirect,    mirror,    as    preliminary  to 
peroral  endoscopy,  64 
Laryngostomy     in     chronic     laryngeal 
stenosis,  307 
Jackson's  method  of,  306 
Laryngo  tracheobronchitis,       influenzal, 
226 
diphtheria  and,  differentiation,  226 
Larynx,  abscess  of,  221 
adenoma  in,  201 
adult,    operative    work    on,    tubular 

laryngoscope  for,  19 
amyloid  tumors  of,  202 
anatomy,  52 
angioma  in,  202 
anterior  portion  of,  removal  of  growths 

in,  91 
benign  growth  in,  201 

removal  of,  91 
cancer   of,    papilloma   and,    differen- 
tiation, 204 
cicatricial  stenoses  of,  metallic  bougie 
for,  43,  46 
webs  of,  aphonia  due  to,  223 
closure  of,  mechanism  of,  52 
congenital  webs  of,  223 
cystoma  in,  201 
diffuse  teleangiectasis  in,  202 
diseases  of,  direct  laryngoscopy  in,  221 


Larynx,  diseases  of,  anesthesia  in,  221 
edema  of,  277 
enchondroma  in,  202 
endoscopy  in  malignant  disease  of,  210 
exposure  of,  prevention  of,  by  wide 

gagging,  32 
extraction  of  foreign  body  from,  modi- 
fied Trendelenburg  position  for,  81 
fibroma  in,  201 
foreign  body  in,  133,  149 
diagnosis,  155 
laryngeal  diphtheria  simulating, 

156 
removal  of,  156 
anesthesia  for,  157 
diagnosis,  156 
position  for,   156 
preliminary   examination,    156 
roentgenogram  as  preliminary, 

156 
symptoms,  156 
technic,  156 
site  of  lodgment,  149 
symptoms,  128 
granuloma   in,    201 
hemorrhage  within,  method  of  stop- 
ping, 96 
infant,    exposure    and    diagnosis    of, 

laryngoscope  for,  19 
introduction    of    direct    laryngoscope 
and    exposure    of,    first    stage.    84 
second  stage,  84 
irregular  foreign  bodies  in,   rotation 

forceps  for  removal  of,  34 
lymphoma  in,  202 

malignant  disease  of,  radium  in,  212 
roentgenray  in,  212 
suspected,    inspection    of    party 

wall  in,  212 
tracheotomy  in,  212 
mirror  examination  of,  importance  of, 

82 
normal,   subglottic   edema   occurring 

in,  causes,  155 
of  adults,  laryngeal  growths  in,  differ- 
ential diagnosis  of,  211 
osteoma  in,  202 
papilloma  of,  in  adults,  205 


INDEX 


335 


Larynx,  papilloma  of,  in  children,  203 
classes  of  cases,  203 
dyspnea  in,  205 

endolaryngeal  extirpation  of,  204 
methods  of  treatment,  203 
radical  removal  of,  205 
repeated  superficial  removal  in, 
204 
recurrent,  302 
paralysis    of,    anesthesia    by    intra- 
tracheal insufflation  in,  68 
perichondritis  of ,  221 

acute  laryngeal  stenosis  in  infants 
from,  278 
posticus     paralysis     of,     ventriculo- 

cordectomy  for,  94 
preliminary     examination     of,     with 
tongue  depressor  before  esophagos- 
copy,  237 
removal  of  larger  growths  from,  large 
basket  punch  forceps   for,   38,   40 
scleroma  of,  304 

stenosis     of,     acromegalic,    tracheot- 
omy for,  280 
acute,  277 

complicating  typhoid  fever,  277 
etiology,  277 

in   infants   from  laryngeal   peri- 
chondritis, 278 
surgical  treatment  of,  278 
chronic,  300 

intubational  treatment  in,  307 
laryngoscopic  bouginage  in,  306 
laryngostomy  in,  306 
method,  307 
postdiphtheritic,  304 
traumatic  factors  in,  305 
cicatricial,  treatment,  306 
decannulation  after  cure  of,  309 
in  newborn,  278 
leutic,  304 
neoplastic,  302 
paralytic,  301 

from   forceps  deliveries,  278 
subglottic  hypertrophic,  305 
supraglottic  hypertrophic,  304 
true  myxoma  of,  202 
tuberculosis  of,  221 


Larynx,   tuberculosis  of,  galvanopunc- 
ture  for,  222 
tuberculous  infiltrations  of,  galvano- 

cautery  puncture  for,  95 
tumor  of  upper  part,  Jackson's  ex- 

tubal  method  for  removal  of,  93 
true  lipoma  of,  202 
ulcerative  lesions  in,  during  typhoid 

fever,  305 
ventricles  of,  53 

exposure  of,  with  anterior  commis- 
sure laryngoscope,  19 
web  formations  in,  removal  of,  94 
Lateral  method  of  exposing  growth  in 

ventricle  of  Morgagni,  92 
Lavage     treatment    of    bronchiectasis, 

drainage  bronchoscope  for,  19 
Leeches,  removal  of,  from  tracheobron- 
chial tree,  174 
Lens-system  ballooning  gastroscopy,  275 

gastroscope,  Janeway,  275 
Liberation  of  adhesions  for  formation  of 

adventitious  vocal  cords,  94 
Light    reflex    in    judging    distance    of 
inserting  forceps,  119 
on    forceps    in   gauging    depth   of 
insertion  of  instruments,  160 
Light-carriers,  sterilization  of,  49 
Lip  of  bronchoscope  in  disimpaction  of 
foreign  bodies,  172 
valuable  aid  in  solution  of  foreign 
body  problems,  160 
upper,   removal  of,   from   danger   of 
pinching,  76 
Lipoma,  true  of  larynx,  202 
Lips,  mouth,  and  gums  of  child,  wound- 
ing of,  90 
Lues    in    laryngeal    growths    in    adult 
larynx,  differential  diagnosis,  211 
of  esophagus,  269 
of  tracheobronchial  tree,  231 
Leutic  laryngeal  stenosis,  304 

ulcer  of  esophagus,  240 
Lukens,  215,  228 

Lumen,  esophageal,  diameter  of,   59 
full,  esophagoscope,  22 
large,  laryngoscope,  18 
Lump  in  the  throat,  246 


33^ 


INDEX 


Lung,  abscess  of,  227 
chronic,  228 
lung-mapping  in,  229 
drowned,  129 

in  foreign  body  in  bronchi,   179 
gangrene  of,  229 
Lung- mapping  in  pulmonary  abscess,  229 

Jackson's  method,  141,  142 
Lupoid  laryngeal  tuberculosis,  differen- 
tial diagnosis  of,  in  laryngeal  growths 
in  adult  larynx,  211 
Lye  preparations,  commercial,  dangers 

in  use  of,  251 
Lymphoma  in  larynx,  202 

MacN.-vb,  250 

Malignant  disease  of  epiglottis,  210 
of  esophagus,  216 
bouginage  in,  219 
diagnosis,  217 

esophageal    intubation  in,     219 
esophagoscopic     appearance     of, 

218 
gastrostomy  in,  219 
radiotherapy  in,  220 
roentgenray  in,  220 
sites  of  lesion,  216 
symptoms,  216 
treatment,  219 
of  larynx,  endoscopy  in,  210 
radium  in,  212 
roentgenray  in,  212 
suspected,    inspection    of    party 

wall  in,  212 
tracheotomy  in,  212 
growths  of  trachea,  bronchoscopy  in, 
214 
radium  in,  215 
treatment,  214 
Malleable  tracheotomic  aspirating  tube, 

Jackson's,  28 
Mandrins,  dangers  in  use  of,  24 
Manikin,  rubber-tube,  121 

mechanical  problems  of  foreign  body 

extraction,  158 
practice  on,  120 
Manges  (Willis  F.),  35,  139 
IVIanges'  double-planed  fluoroscope,  276 


Mapping,  bronchial,  Jackson's  method, 

141,  142 
Marbles,   extraction  of,   from  bronchi, 

172 
Matas,  265 

McCrae,  Thomas,  134,  136, 144,  145, 146 
McCready-McKee       modification       of 

Boyce  thimble,  32 
McKee-McCready       modification       of 

Boyce  thimble,  32 
Measuring  rule  for  locating  esophageal 

lesions,  26 
Meat   and   other  foods,  removal  from 
esophagus,  196 
bolus   of,   mechanical   spoon   for   re- 
moval of,  42,  45 
Mechanical  aspirator,  Robinson's,  29 
problems    of    bronchoscopic    foreign 
body  extraction,    158.     See  also 
Foreign  body  extraction,  bronchos- 
copic, mechanical  problems. 
of  esophagoscopic  removal  of  foreign 
bodies,    190.     See    also    Foreign 
body    extraction,    esophagoscopic, 
mechanical  problems. 
spoon,  bronchoscopic,  Jackson's,  42, 

45 
esophagoscopic,   Jackson's,   42,   45 
short,  Jackson's,  39 
Mechanism    of    perforation    by    blind 
bouginage   in   cicatricial   stenosis   of 
esophagus,  253 
Meissner  and  Auerbach  plexus,  245 
Meltzer  and  Auer,  29 
Mesothorium   for  papilloma  of   larynx 

in   children,    204 
Metallic  bodies,  hollow,  extraction  of, 
mechanical  problem  of,  167 
bougie    for    cicatricial    stenoses    of 
larynx,  43,  46 
of  trachea,  42,  46 
Mirror  examination  of  larynx,   impor- 
tance of,  82 
throat,  examination  of  patient  with, 
before  general  anesthesia,  68 
Modified    Trendelenburg    position    for 
extraction    of    foreign    bodies    from 
larynx,  81 


i 


I 


INDEX 


337 


Moore,  125,  228 

Morbidity  of  bronchoscopy,  151 

Morgagni,  ventricle  of,  lateral  method  of 

exposing  growth  in,  92 
jMorphin  for  anesthetizing  dog,  123 
in  controlling  hemorrhage,  g6 
sulphate   preceding   bronchoscopy  in 

older  children,  65 
when  cocain  is  contraindicated,  67 
Mortality  of  bronchoscopy,  151 
Mosher,  114,  247,  249,  265 
Mosher's  divulsor,  249 
laryngeal  curette,  41 
grasping  forceps,  32 
Mosquito  forceps,  35 
Motor  paralysis  of  esophagus,  268 
Mouth,  gums,  and  lips  of  child,  wound- 
ing, of,  90 
inducing    child    to    open,    Jackson's 

method,  90 
wash,  198 
Mouth-gag,  32 

Jackson's,  for  use  on  dog,  123 
Movements  of  esophagus,  extrinsic,  61 
intrinsic,  61 
pulsatory,  61 
respiratory,  61 
transmitted,  61 
of  trachea  and  bronchi,  normal,  57 
Mucosa,  bronchial,  color  of,  224 
gastric,  appearance,  112 
normal  esophageal,   appearance,   112 
Muller,  Geo.  P.,  29 
Multiple  papilloma  in  tracheobronchial 
tree,  Jackson's  coring  method  for,  208 
Muscle,  cricopharyngeal,  60 
Mushroom    anchor   problem    of    brass 
upholstery  tack,  167,  168 
with  upper-lobe-brdnchus  problem, 
Jackson's  method  of  solution,  169 
Myxoma,  true  of  larynx,  202 

Nail,  inward  rotation  method  of  ex- 
tracting, Jackson's,  165,  166 

Nails,  extraction  of,  from  tracheobron- 
chial tree,  Jackson's  inward  rotation 
method  for,  167 

Narrowing  of  esophagus,  aortic,  60 


Narrowing  of  esophagus,  bronchial,  60 
hiatal,  60 

Needles,  extraction  of,  mechanical  prob- 
lem of,  164,  165,  166 

Neoplasms  of  esophagus,  benign,  209 

Neoplastic  stenosis  of  larynx,  302 

Nerve  cell  habit  as  perpetuating  cause 
of  spasmodic  stenosis  of  esophagus,  245 

Newborn,  stenosis  of  larynx  in,  278 

Newcomet,  215,  220 

Nickle  plating  on  tubes,  care  of,  49 

Nodules  on  vocal  cords,  removal  of,  201 
vocal-nodule    forceps    for,    40 

Non-roentgenopaque  objects,  fluoro- 
scopic study  of  swallowing  function 
with  barium  mixture  for  location  of, 
138 

Normal    esophageal    mucosa,    appear- 
ance, 112 
position  of  intra-thoracic  trachea  and 
esophagus,  73 

Nurse,  instrument,  50 
spectacle,  duties,  45 

Nursing  of  tracheotomized  patients,  298 

Obstruction,  bronchial,  complete,  phys- 
ical signs  in,  135 
roentgenographic  signs  in,  139 
expiratory  valve-like,  physical  signs 

in,  135 
roentgenographic  signs  of,  138 
partial,  physical  signs  in,  136 
prolonged,  by  foreign  body,  137 
of   canal    during   esophagoscopy,    23 
Occipito-atloid  extension  with  high  head 

position,  obtaining,  79 
Odynphagia,  palliation  of,  in  tuberculous 
or  malignant  disease,  amputation  of 
epiglottis  for,  93 
Open  safety  pin,  extraction  from  esopha- 
gus, 192 
without      closing,      Jackson's 
method,  170 
in  esophagus,  endogastric  version 
for  removal  of,  193 
version  for  removal,  193 
lodged  point   up,   extraction   of, 
169 


338 


INDEX 


Cpen    safety    pin,    removal    of,    from 
trachea  and  bronchi,  169 
upward    pointing,    in    children, 
spatula-protected   method   for 
removal,  193 
Operating  room,   47 
arrangement  of,  47 
asepsis  in,  47,  48 
light  of,  45 
Operator,  position  of  eyes  in  operating, 

45 
Opisthotonous  position,  overcoming,  80 
Oral  bronchoscopy,  schema  illustrating, 

99 
Orthoform    for    painful    swallowing    in 

foreign  body  in  esophagus,  185 
Osteoma  in  larynx,  202 
Over-illuminating   lamps,    as    cause   of 

trouble,  117 
Overriding    esophageal    foreign    body, 

factors  in,  189 
Oxygen  and   amyl  nitrite  for  bronchos- 
copic  oxygen  insufflation,  72 
for  respiratory  arrest,  48 

insufflation  of,  bronchoscope  for,  19 
bronchoscopic,  71 

tank,  48 
Ozena,    tracheal,    233 

Palliation  of  odj^nphagia  or  dysphagia 
in  tuberculous  or  malignant  disease, 
amputation  of  epiglottis  for,  93 
Palpatory  thud,  134 
Pancoast.  220 
Panic  in  decannulation,  in  tracheotomy, 

300 
Papilloma,  aspirating  tube  for  removing, 
28 
forceps,  Jackson's,  39,  40 
multiple,     in     tracheobronchial    tree 
Jackson's  coring  method  for,   208 
of  larynx,  cancer  of  larynx  and,  differ- 
entiation, 204 
in  adults,  205 
in  children,  203 

classes  of  cases,  203 

dyspnea  in,  205 

endolaryngeal  extirpation  of,  204 


Papilloma  of  larynx  in  children,  methods 
of  treatment,  203 
radical  removal  of,  205 
repeated  superficial  removal  in, 
204 
recurrent,  of  larynx  and  trachea,  302 
Paralysis,  laryngeal,  associated  with  com- 
pression stenosis  of  esophagus,  243 
of  esophagus,  268 
diagnosis,  269 

esophagoscopic  findings  in,  269 
etiology,  268 
motor,  268 
sensory,  268 
treatment,  269 
of  larynx,  anesthesia  by  intratracheal 
insufflation  in,  68 
Paralytic  stenosis  of  larynx,  301 
from  forceps  deliveries,  278 
Patient,  adult,  direct  laryngoscopy  in,  83 
instructions  to,  before  endoscopy,  83 
position  of,  for  peroral  endoscopy,  73 
preparation  of,   for   endoscopic   pro- 
cedures, 48 
for  peroral  endoscopy,  63 
Patterson,  64 

Peanut  forceps,  fenestrated,  Jackson's,  37 
kernel  in  bronchus,  early  symptoms 

of,  129 
kernels,     aspiration     of,     edematous 
tracheobronchitis  from,  227 
Pebbles,  extraction  of,  from  bronchi,  172 
Pedunculated    subglottic    growth,     re- 
moval of,  91 
Penetrating  projectiles,  removal  of,  174 
Perforating  esophageal  wall,  risk  of,  in 

introducing  esophagoscope,  24 
Perforation  by  blind  bouginage,  mechan- 
ism   of,    irf  cicatricial    stenosis    of 
esophagus,  253 
esophagoscopic,  point  of,  60 
of  esophagus,  238 

as    contraindication  to   esophagos- 
copy,  188 
of  pleura,  188 
treatment,  198 
Perichondritis  from  too  deep  cauteriza- 
tions, 95 


INDEX 


339 


Perichondritis,  laryngeal,  acute  laryn- 
geal stenosis  in  infants,  from,  278 
of  larynx,  221 
Peroral   endoscopy,   anesthesia   for,    65 
position  of  patient  for,  73 
preparation  of  patient  for,  63 
Pfahler,  220 

Pharyngeal  secretions,  aspiration  of  dur- 
ing   direct    laryngoscopy,    aspirating 
tube  for,  28 
Pharynx,   preliminary   examination   of, 
with  tongue  depressor  before  esoph- 
agoscopy,  237 
removal  of  larger  growths  from,  large 
basket  punch  forceps  for,  38,  40 
Phrenospasm,  62,  245,  247 
Physical  examination,  general,  in  foreign 
body    in     air    and     food     passages, 
132 
Pin-buttons,  esophagoscopic  removal  of, 

rotation  forceps  for,  34 
Pin-closer,   Arrowsmith's,   42,   45,    170, 

192 
Pinchcock,  diaphragmatic,  61,  62,  247 

cramp  of,  250 
Pins,  extraction  of,  mechanical  problem 
of,  164,  165,  166 
safety,  open,  extraction  from  esopha- 
gus, 192 
without      closing,      Jackson's 
method,  170 
in  esophagus,  endogastric  version 
for  removal  of,  193 
version  for  removal,  193 
lodged  point  up,   extraction   of, 

169 
removal  of,     from    trachea    and 

bronchi,  169 
upward     pointing     in     children 
spatula-protected   method   for 
removing,  193 
screw  forceps  for  removal  of,  36 
Plate,  tooth,  extraction  from  esophagus, 

196 
Pleura,  perforation  of,  198 
Pleural   cavity   foreign   bodies   in,    199 
diseases,  pleuroscopy  for,  199 
perforation,     188 


Pleuroscopes,  26 

anterior  commissure  laryngoscope  as, 

19,  26 
esophageal  specula  as,  25,  26 
Pleuroscopy,  199 

for  diseases  of  pleura,  199 
for  foreign  bodies  in  pleural  cavity,  199 
Plexus,    Auerbach    and    Meissner,    245 
Plica    cricopharyngeus,    folding    down- 
ward of,  hiding  coin,  189 
Pocket  battery  not  dependable,  27 
Pointed  cautery  electrode,  41 

objects,     extraction    of,     mechanical 

problem  of,  164,  165,  166 
tacks,  double,  removal  of,  171 
Poisoning  by  chlorine  and  irritant  gases, 
bronchial  aspiration  and  bronchos- 
copic  oxygen  insufflation  in,  291 
cocain,  197 
Portable   aspirator   for   endoscopy,    29 
Position,  Boyce,  for  esophagoscopy  and 
bronchoscopy,  77 
correct,  of  cervical  spine  for  esophagos- 
copy and  bronchoscopy,  74 
curved,  of  cervical  spine,  with  anterior 

convexity  in  Rose  position,  75 
faulty,  for  endoscopy,  79,  80 
for  bronchoscopy,  46,  76 
for  direct  laryngoscopy,  76 
for  endoscopy,  78 
for  esophagoscopy,  46,  76 
for  peroral  endoscopy,  73 
normal,  of  intra-thoracic  trachea  and 

esophagus,  73 
of    high    head    with    occipito-atloid 

extension,  obtaining,  79 
of    patient    for    peroral    endoscopy, 

general  principles,  73 
opisthotonous,  overcoming,  80 
Rose,  73,  74 
Positive  films  of  tracheobronchial  tree 

as  aid  to  localization,  140 
Postdiphtheric   subglottic   stenosis,   re- 
production    of     Jackson's     oil-color 
drawing,  from  life,  Plate  IV,  facing  p. 

273 
Post-tonsillectomy    abscesses,    medica- 
ment in,  228 


340 


INDEX 


Practice  on  cadaver,  120 
on  dog,  122 

on  rubber-tube  manikin,  120 
tiiread,   with   bronchoscope   and   for- 
ceps, 119 
Presentation,    study  of,   in   mechanical 
problemsofforeignbody  extraction,  159 
Proctoclysis,  187 

Projectiles,  penetrating,  removal  of,  174 
Prolonged     foreign     body     sojourn     in 

bronchus,  symptoms,  129 
Prophylaxis  for  foreign  bodies  in  food 

and  air  passages,  126 
Protected-aperture   endoscopic   aspirat- 
ing tube,  Jackson's,  28 
Protective  reflexes  of  lower  air  passages, 

149 
Pulmonary  abscesses,  drainage  of,  drain- 
age bronchoscope  for,  19 
hemostasis  by  bronchoscopic  tampon- 
ade, Jackson's  tampon  for,  232 
Pulsatory  movements  of  esophagus,  61 
Pulsion  diverticulum,  60 
of  esophagus,  261 

esophagoscopic    appearances    in, 

264 
treatment,  265 
Punch,  large  basket,  forceps,  38 
Puncture,  galvano-cautery,  for  tubercu- 
lous infiltrations  of  larynx,  95 
Pyriform  sinus,  landmark  of,  107 

Quick,  213 

Radium,    application    of,    95 

for  papilloma  of  larynx  in  children,  204 
in  angioma  of  larynx,  202 
in  malignant  disease  of  esophagus,  220 
of  larynx,  212 
growths  of  trachea,  215 
Rectal  feeding  in  water  starvation,  237 
Reflex,    light,    in    judging  distance  of 
inserting  forceps,  119 
on   forceps,    in   gauging   depth   of 
insertion  of  instruments,  160 
Reflexes,  protective,  of  lower  air  pas- 
sages, 149 
Regurgitation   of   food    from   stomach, 
normal  prevention  of,  62 


Repair  of  instruments,  51 
Respiration,    artificial,    197,    283,    289 
Respiratory    arrest    during    endoscopic 
procedures,  48 
movements  of  esophagus,  6r 
Resuscitation,  means  for,  in  respiratory 
arrest  during  endoscopic  procedures, 
48 
Retaining  intubation  tube  for  treatment 
of  chronic   laryngeal   stenosis,   Jack- 
son's, 307 
Retrograde  esophageal  bougie,  Jackson 
and  Tucker's,  41 
esophagoscope,  Jackson's,  22,  47 
esophagoscopy,  115,  116 

in  cicatricial  stenosis  of  esophagus, 
258 
Retropharyngeal  abscesses,  draining  of, 

aspirating  tube  for,  28 
Robinson's  mechanical  aspirator,  29 
Roentgenograms  preliminary-  to  removal 
of     foreign     body     from     larynx, 
156 
study  of,  in  mechanical  problems  of 
foreign  body  extraction,  158 
Roentgenographic    signs    in    complete 
bronchial  obstruction,  139 
in   expiratory   valve-like   bronchial 
obstruction,  138 
Roentgenography,  137 
Roentgenray  for  papilloma  of  larynx  in 

children,  204 
Roentgenray   in    malignant    disease   of 
esophagus,  220 
of  larynx,  212 
study  in  foreign  body  cases,  137 
Rose  position,  73,  74,  109 

curved   position   of   cervical   spine 
with   anterior   convexity   in,    75 
Rotation  forceps,  laryngeal,  34 
Jackson's,  40 
method,  inward,  of  foreign  body  ex- 
traction, Jackson's,  165,  166 
Rubber  covered  conducting  cords,  ster- 
ilization of,  49 
diaphragm  with  perforation  for  for- 
ceps    for     esophagoscope     in     air 
insufflation,  24,  25 


INDEX 


341 


Rubber-lube  manikin,  120 
practice  on,  120 

in  mechanical  problems  in  foreign 
body  extraction,  158 
Rules     for     endoscopic     foreign     body 
extraction,  174 
for  insertion  of  catheter  for  insuffla- 
tion anesthesia,  69 
Rupture  and  trauma  of  esophagus,  238 
cervical,  239 
thoracic,  239 
of    trachea,    subcutaneous,    tracheo- 
tomy for,  279 

Safety-pix  closer,  44 

Arrowsmith's,  42,  45,  170,  192 
esophagoscopic  removal  of,    rotation 

forceps  for,  34 
extraction.    Tucker    forceps    for,    36 
in  bronchus,  upper-lobe-bronchus  for- 
ceps for,  35 
open,     extraction     from     esophagus, 
192 
without        closing,        Jackson's 
method,  170 
in   esophagus,   endogastric   version 
for  removal  of,  193 
version  for  removal,  193 
lodged    point    upward,    endoscopic 
closure       of,        Jackson's 
method,  42,  44 
extraction  of,  169 
removal     of,     from     trachea     and 

bronchi,  169 
upward  pointing  in  children,  spat- 
ula-protected method  for  remov- 
ing, 193 
Salivary  drainage  in  absolute  atresia  of 

esophagus,  259 
Sarcoma  of  larynx  taking  specimen  for 

diagnosis,  92 
Sarcomatous   ulcers   of   esophagus,  241 
SchaefTer  (J.  P.),  120,  215 
Schema  of  position  for  endoscopy,  78 
Scleroma  of  larynx,  304 

of  trachea,  233 
Scissors,^  sterilization  of,  49 
Screw  forceps,  36 


Secretions  lying  close  to  foreign  body, 
aspirating  tube  for  removal  of,  28 
removal  of,  by  aspirator,  during  direct 
laryngoscopy,  87,  91 
Self-expanding  bronchial  dilator,  Jack- 
son's, 37,  42 
Semon,  206 

Sensory  paralysis  of  esophagus,  268 
Shock  as  exciting  cause  of  spasmodic 
stenosis  of  esophagus,  245 
surgical,  after  bronchoscopy,   154 
Short  esophagoscopes,  Jackson's,   23 
heavy  handled  esophagoscope,  23 
with  drainage,  23 
Side-curved   endoscopic   forceps,   Jack- 
son's, jaws  of,  34 
Side-slide  laryngoscope,  19 
Signs  suggestive  of  foreign  body,  146 
Simple  ulcer  of  esophagus,  240 
Sketches,    colored    crayon,    as    aid    to 

accurate  observation  of  larynx,  82 
Skill,  acquiring,  in  endoscopy,  117 
Slant   of   esophagoscope  in   facilitating 

introduction  of,  24 
Slap,  audible,  134,  145 
Soft,  friable  foreign  bodies,  extraction 

from  tracheotronchial  tree,  173 
Soft-rubber  retrograde  dilators  for  gas- 

trostomized  cases,  43 
Spasmodic   stenosis    in   lower   third   of 
esophagus,  site  of,  62 
of  esophagus,  245 

compression  stenosis  simulating, 

249 
cricopharyngeal,  245 
etiology,  245 
treatment,  300 
Spastic  stenosis  of  esophagus,  244 
Spatula-protected  method  for  removing 
upward  pointing  safety  pin  in  esoph- 
agus of  children,  193 
Special  size  bronchoscopes,  21 
esophagoscopes,  22,  24,  25 
Spectacle  nurse,  duties,  45 
Spectacles,  45 
Specular  esophagoscopy,  114 

technic,  114 
Speculum,  esophageal,  adult's  size,     2 


342 


INDEX 


Speculum,     esophageal     and     hypo- 
pharyngoscope,  Jackson's,  23 
as  pleuroscope,  25,  26 
child's  size,  23 
for    operations    on    upper    end    of 

esophagus,  25 
for  removal  of  foreign  bodies,  190 
Jackson's,  23 
Sponge  carrier,  30 

endoscopic,  pattern  for,  31 
gauze,  method  of  making,  32 
sterilization  of,  32 
Sponge-pumping,  30 

removal  of  bronchial  secretions  by, 
21,  31 
Sponging,  caution  in,  in  foreign  body  in 

esophagus,  188 
Spontaneous  expulsion  of  foreign  bodies 

from  air  passages,  150 
Spoon,  mechanical  bronchoscopic,  Jack- 
son's, 42,  45 
esophagoscopic,  Jackson's,  42,  45 
short  mechanical,  Jackson's,  39 
Squamous-celled  epithelioma  of  esopha- 
gus, 216 
Square-cannula  forceps,  35 
Staples,  in  esophagus,  removal  of,  194 
Starvation,   water,   as   contraindication 
to  esophagoscopy,  236 
gastrostomy  in,  237 
rectal  feeding  in,  237 
relief  of,  before  endoscopy,  64 
in  foreign  body  in  esophagus,  187 
Stenosis,  bronchial,  229 

cicatricial,  of  esophagus,  251 

dilatation     of,    by      endoscopic 
method,  43 
laryngeal,    endoscopic    evisceration 
of  larynx  for,  94 
metallic  bougie  for,  43,  46 
of  trachea,  metallic  bougie  for,  42, 
46 
compression,    endoscopic   picture    of, 
225 
of  bronchi,  treatment,  226 
of  esophagus,  243.      See  also  Sle-  I 

nosis  of  esophagus,  compression. 
of  trachea  and  bronchi,  225,  302 


Stenosis,   compression,   of  trachea  and 
bronchi,  treatment,  225 
diaphragmatic    pinchcock,    247,    250 
hiatal  functional,  62 
of  esophagus,  cicatricial,  251 
compression,  243 
appearances  in,  243 
lesions  associated  with,  243 
treatment  of,  243 
cricopharyngeal  spasmodic,  245 
functional  hiatal,  247,  250 
Jackson's  sign,  237,  268 
spasmodic,  245 

compression  stenosis  simulating, 

249 
etiology,  245 
spastic,  244 
of   larynx,   acromegalic,  tracheotomy 
for,  280 
acute,  277 

complicating  typhoid  fever,   277 
etiology,  277 

in  infants,  from  laryngeal  peri- 
chondritis, 278 
surgical  treatment,  278 
chronic,  intubational  treatment  in, 

307 
laryngoscopic  bouginage  in,  306 
laryngostomy  in,  306 
method,  307 
postdiphtheritic,  304 
traumatic  factors  in,  305 
cicatricial,  treatment,  306 
decannulation  after  cure  of,  309 
endoscopic  operations  for,  94 
in  new  born,  278 
leutic,  304 
paralytic,  301 

from  forceps  deliveries,  278 
subglottic  hypertrophic,  305 
supraglottic  hj^ertrophic,  304 
of  trachea,  compression,  225,  302 
spasmodic,  in  lower .  third  of  esoph- 
agus, site  of,  62 
treatment,  300 
Sterilization,  continuous,  49,  51 
of  endoscopic  battery,  27 
sponges,  32 


INDEX 


343 


Sterilization  of  instruments,  49 

Stick  pins,  inward  rotation  method  for 

extraction  of,  Jackson's,  167 
Stomach,  ballooning  of,  in  gastroscopy, 
274 
foreign  bodies  in,  127 

symptoms,  131 
regurgitation   of   food   from,    normal 
prevention  of,  62 
Stout,  289 
Strictured     esophagus,     extraction     of 

foreign  bodies  from,  196 
Strictures  above  foreign  bodies,   bron- 
chial dilators  for,  37,  40 
of  esophagus,  congenital,  237 
series  of,  endoscopic  divulsor  for,  41 
Stridor,  laryngeal,  congenital,  222 

treatment,  223 
String-swallowing  in  cicatricial  stenosis 

of  esophagus,  257 
Stripping  of  foreign  body  from  forceps 

at  glottis,  164 
Subcutaneous  emphysema,  239 
Subglottic  edema  after  bronchoscopy,  154 
treatment,  155 
chronic,  cauterization  for,  221 
occurring     in     previously     normal 
larynx,  causes  of,  155 
hypertrophic   stenosis  of  larynx,  305 
pedunculated  growth,  removal  of,  91 
region,  anterior  commissure  laryngo- 
scope for  work  in,  19 
Supraglottic  edema  following  broncho- 
scopy, 154 
hypertrophic  stenosis,  of  larynx,  304 
Surgical  shock  after  bronchoscopy,  154 
Swallowing  function,  fluoroscopic  study 
of,  with  barium  mixture  for  location 
of  non-roentgenopaque  object,  138 
Symptomatology  of  foreign  bodies,  127 
Syphilis.      See  also  Lues. 
of  esophagus,  269 
esophagoscopic  appearances  in,  269 
diagnosis,  270 
treatment,  270 
of  tracheobronchial  tree,  231 

Table,  bronchoscopic,  Jackson's,  46 
endoscopic,  46 


Table,  esophagoscopic,  Jackson's,  46 
Tacks,  bronchial  dilators  for  removal  of, 
37,  40 
double  pointed,  in  esophagus,  removal 
of,  194 
removal  of,  171 
extraction  of,  from  tracheobronchial 
tree,     Jackson's     inward     rotation 
method  for,  167 
inward  rotation  method  for  extract- 
ing, Jackson's,  165,  166 
screw  forceps  for  removal  of,  36 
upholstery,  brass,  mushroom  anchor 
problem  of,  167,  168 
with  buried  point,  extraction  of, 
mechanical    problem    of,    168 
Tamponade,    bronchoscopic,    Jackson's 

tampon  for,  232 
Tampons,    Jackson's,     for    pulmonary 
hemostasis  by  bronchoscopic  tampon- 
ade, 232 
Teleangiectasis,  diffuse,  in  larynx,   202 
Temperature   after   bronchoscopy,    153 
Testing  for  electric  defects,  118 
Thermic  bouginage  in  cicatricial  steno- 
sis of  esophagus,  257 
Thimble,      Boyce,      McKee-McCready 

modification  of,  32 
Thoracic  esophagus,  rupture  of,  239 
Thoracotomy  for  foreign  body,  182 
Thread  practice  with  bronchoscope  and 

forceps,  119 
Throat,  lump  in,  246 

mirror,  examination  of  patient  with, 
before  general  anesthesia,  68 
Thud,  palpatory,  134 
Thumb  tacks,  inward  rotation  method 

for  extraction  of,  Jackson's,  167 
Thyroid  tumors,  aberrant,  in  larynx,  202 
Thyroidectomy,  monolateral  and  bilat- 
eral paralysis  of  larynx  as  sequel  to,  303 
Tightly  fitting  foreign  bodies  in  bronchi, 
mechanical  problems  in  extraction  of, 
172 
Tissue  forceps,  endoscopic,  Jackson's,  37 
larjmgeal,  extra  large,  40 
removal  of,  for  biopsy,  forceps  for, 
37,38 


344 


INDEX 


Toggle  and  ring  action  in  removal    of 

open  safety  pin,  169 
Tooth   plates,   esophagoscopic   removal 
of,  rotation  forceps  for,  34 
extraction,  from  esophagus,   196 
Trachea,  anatomy,  53 

and  esophagus,  intra-thoracic,  normal 

position  of,  73 
bronchoscopy  in  diseases  of,  224 
cicatricial  stenoses  of,  metallic  bougie 

for,  42,  46 
compression  stenosis  of,  225,  302 

treatment,  225 
dimensions  of,  56 
examination  of,  102 
foreign  body  in,  physical  signs,   133 

symptoms,  128 
incision  in,  in  tracheotomy,  285 
malignant  growths  of,  bronchoscopy 
in,  214 
radium  in,  215 
treatment,  214 
normal  movements  of,  57 
papilloma  of,  recurrent,  302 
removal  of  open  safety  pins  from,  169 
rupture    of,    subcutaneous,    tracheo- 
tomy for,  279 
scleroma  of,  233 
stenosis  of,  chronic,  300 
compression,  225,  302 
treatment,  225 
Tracheal  cannulae,  endoscopic  removal 
of,  expansile  forceps  for,  36 
flutter  in  foreign  body  cases,  144 
ozena,  233 

symptoms  in  foreign  body  cases,  144 
Tracheitis,  atrophic,  233 
Tracheobronchial  diphtheria,  227 
tree,  54 

anomalies  of,  225 

aspirating     tube    for    removal    of 
secretions,   exudates,    etc.    from, 
through       tracheotomic    wound 
without  a  bronchoscope,  28 
benign  growths  primary  in,  207 

bronchoscopic     removal    of, 

207 
symptoms,  207 


Tracheobronchial    tree,    cadaveric   di- 
mensions of,  56 
extraction    of   soft    friable    foreign 

bodies  from,  173 
foreign  bodies  in,  149 

site  of  lodgment,  149 
lues  of,  231 
multiple    papilloma    in,    Jackson's 

coring  method  for,  208 
positive  films  of,  as  aid  to  localiza- 
tion, 140 
removal  of  animal  objects  from,  174 
tuberculosis  of,  231 
Tracheobronchitis,  edematous,  226 

resulting  from  aspiration  of  irritat- 
ing liquids  or  vapors  and  organic 
substances,  227 
Tracheotomic  aspirating  tube,   mallea- 
ble, Jackson's,  28 
cannulae,  281 

corks  for,  method  of  making,  310 
Jackson's,  282 
triangle,  Jackson's,  286 
Tracheotomized  patient,  anesthetizing, 
68 
nursing  of,  298 
Tracheotomy,  279,  280 
after-care,  289 

resume  of,  295 
anesthesia  for,  283 
classical  descriptions  of,  280 
contraindications  for,  280 
cough-sedatives  or  narcotics  in,  284, 

298 
decannulation  in,  291 
emergency,  287 

Jackson's  two  stage  finger  guided 

method,  287 
resume  of,  teaching  notes,  294 
schema  of  practical  gross  anatomy 
to  be  memorized  for,  286 
for  acromegalic  stenosis  of  larynx,  280 
for  foreign  body,  279 
for  subcutaneous  rupture  of  trachea, 

279 
in  malignant  disease  of  larynx,   212 
incision  of  trachea  in,  285 
indications  for,  279 


INDEX 


345 


Tracheotomy,  instruments  for,  48,  280 

method  of  dressing  wound,  289 

nursing  in,  298 

panic  in  decannulation,  300 

resume  of,  teaching  notes,  293 

technic,  284 
Traction  diverticulum  of  esophagus,  260 

on  irregularly  shaped   foreign   body, 

rotation  forceps  for,  34 

Transmitted  movements  of  esophagus,  61 

Trauma  and  rupture  of  esophagus,  238 

Traumatic  esophagitis,   treatment,   239 

factors  in  chronic  laryngeal  stenosis, 

305 
Trendelenberg    position,    modified,    for 
extraction    of    foreign    bodies    from 
larynx,  81 
Triangle,  tracheotomic,  Jackson's,   286 
Tube   mouth,   anchoring   foreign   body 
against,  method,  163 
and   foreign   body,   relation  of,   in 
foreign  body  problems,   160 
Tuberculoma  of  larynx,  222 
Tuberculosis   in    laryngeal   growths   in 
adult  larynx,  differential  diagnosis 
of,  211 
of  esophagus,  270 
diagnosis,  271 
treatment,  271 
of  larynx,  221 

galvanopuncture  for,  222 
of  tracheobronchial  tree,  231 
preventing  decannulation,  304 
Tuberculous     disease,     amputation     of 
epiglottis   for   palliation   of   odyn- 
phagia or  dysphagia  in,  93 
infiltrations   of   larynx,   galvano-cau- 

tery  puncture  for,  95 
ulcer  of  esophagus,  241 
Tubes,  aspirating,  27 

tracheotomic,  malleable,  Jackson's, 
28 
cleaning  of,  50 
endoscopic  aspirating,  protected-aper- 

ture,  28 
retaining  intubation,  for  treatment  of 

chronic  laryngeal  stenosis,  307 
sterilization  of,  49 


Tubular  laryngoscope,  19 

Tucker,  36,  79,  166,  170,  172 

Tucker  forceps,  36,  167,  192,  193 
jaws  for  Jackson's  forceps,  35 

Tucker  and  Jackson's  retrograde  esopha- 
geal bougie,  41 

Tumors,    aberrant   thyroid,   in   larynx, 
202 
amyloid  of  larynx,  202 
benign,  large,  above  cords,  removal  of, 

93 
of  tracheobronchial  tree,  symptoms 
of,  207 
of  esophagus,  benign,  209 
of    upper    part    of  larynx,    Jackson's 
extubal  method  for  removal  of,  93 
Turner,  Logan,  154 

Tj^hoid  fever,  acute  laryngeal  stenosis 
complicating,  277 
preventing  decannulation,  305 

Ulcer  of  esophagus,  240 
carcinomatous,  241 
differential  diagnosis,  240 
luetic,  240 
sarcomatous,  241 
simple,  240 
tuberculous,  241 
Ulcerative    lesions    in    larynx    during 

tj^jhoid  fever,  305 
Unsuccessful  bronchoscopy  for  foreign 

bodies,  181 
Upholstery     tack,     brass,     mushroom 
anchor  problem  of,  167,  168 
with  buried  point,  extraction  of, 
mechanical  problem  of,  168 
Upper  lip,  removal  of,  from  danger  of 

pinching,  76 
Upper-lobe  bronchus,  coil-spring    hook 
for,  Jackson's,  44 
forceps,  35 

foreign  bodies  in,  removal  of,  174 
problem,  mushroom-anchor    prob- 
lem  with,  Jackson's   method   of 
solution,  169 
Use  of  forceps,  efficient,  119 

in  endoscopic  foreign  body  extrac- 
tion, 161,  162 


346 


INDEX 


Valve-like    obstruction    of    bronchus, 
expiratory,    physical    signs    in,     135 
Varix  of  esophagus,  271 
Ventricle  of  Morgagni,  lateral  method  of 

exposing  growth  in,  92 
Ventricles  of  larynx,  53 

exposure  of,  with  anterior  commis- 
sure laryngoscope,  19 
removal  of  growths  from,  92 
Ventricular  bands,  53 
Ventriculocordectomy,      in       paralytic 
laryngeal  stenosis,  301 
in   posticus   paralysis   of   larynx,    94 
Version,    endogastric,    for    removal    of 
open  safety  pin  in  esophagus,  193 
for    removal    of    broad    flat    foreign 
bodies  with  sharp  point  from  eso- 
phagus, 191,  192 
of  safety  pin  in  esophagus  for  removal, 

193 
removal  of  double  pointed  tacks  by, 

171 
removal  of  small  safety  pin  by,    1 70 
Vocal  cords,  53 

adventitious,  liberation  of  adhesions 

for  formation  of,  94 
damage  to,  avoiding,  in  laryngeal 

operations,  91 
false,  S3 

large  benign  tumors  above,  removal 
of,  93 


Vocal  cords,  nodules  on,  galvanocautery 
for,  201 
removal  of,  201 
nodules,  removal  of,  201 
results  of  direct  laryngoscopy,  94 
Vocal- nodule  forceps,  Jackson's,  40 
Voice,     impairment    of,     avoiding,     in 
laryngeal  operations,  91 

Water  starvation  as  contraindication 
to  esophagoscopy,  236 
gastrostomy  in,  237 
rectal  feeding  in,  237 
relief  of,  before  endoscopy,  64 
in  foreign  body  in  esophagus,  187 
Watermelon  seeds,  aspiration  of,  edema- 
tous tracheobronchitis  from,  227 
Watkins,  233 

Webs  in  upper  third  of  esophagus,  238 

of  larynx,  congenital,  223 

removal  of,  94 

Wheeze,    asthmatoid,    as   confirmatory 

sign  of  bronchial  foreign  body,   136 

Wide  gagging,  prevention  of    exposure 

of  larynx  by,  32 
Window    plug    for    esophagoscope    for 
ballooning  esophagus  with  air,  24,  25 
Wounding  of  child's  mouth,  gums,  and 

lips,  90 
Wright,  242 


University  of  Caiifomia 

SOUTHERN  REGIONAL  LIBRARY  FACILITY 

405  Hilgard  Avenue,  Los  Angeles,  CA  90024-1388 

Return  this  material  to  the  library 

from  which  it  was  borrowed. 


PRINTED    IN    U.S.A. 


CAT.   NO.   24    161 


'5 


A  000  499  530 


Jackson,  Chevalier. 
Bronchoscojjy  and  esopheigoscopy 


WPlUl 

J12b 

1922 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA.  IRVINE 

IRVINE.  CALIFORNIA  92664 


